Basic Information
| Provider Information | |||||||||
| NPI: | 1437119583 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | GREGORY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1815 OLD OCILLA RD | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317941617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293913535 | ||||||||
| FaxNumber: | 2293913529 | ||||||||
| Practice Location | |||||||||
| Address1: | 1815 OLD OCILLA RD | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317941617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293913535 | ||||||||
| FaxNumber: | 2293913529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 10/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 032121 | GA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 270436 | 01 | GA | BLUE CROSS BLUE SHEILD | OTHER | 00400375A | 05 | GA | MEDICAID |