Basic Information
| Provider Information | |||||||||
| NPI: | 1386668838 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | ROY | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 W 7TH ST | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385011726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317835582 | ||||||||
| FaxNumber: | 9315266760 | ||||||||
| Practice Location | |||||||||
| Address1: | 340 N CEDAR AVE | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385012421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317835353 | ||||||||
| FaxNumber: | 9317834994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 05/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 7610 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5590139 | 01 | TN | BCBS | OTHER | 7100431530 | 05 | KY | MEDICAID | Q023465 | 05 | TN | MEDICAID |