Basic Information
| Provider Information | |||||||||
| NPI: | 1629286745 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | KEISA | ||||||||
| MiddleName: | G. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GODWIN | ||||||||
| OtherFirstName: | KEISA | ||||||||
| OtherMiddleName: | J. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5780 PEACHTREE DUNWOODY ROAD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043031224 | ||||||||
| FaxNumber: | 4043031325 | ||||||||
| Practice Location | |||||||||
| Address1: | 5780 PEACHTREE DUNWOODY ROAD | ||||||||
| Address2: | SUITE 295 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042550621 | ||||||||
| FaxNumber: | 4042520822 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| LastUpdateDate: | 10/29/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 59159 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 688965242D | 05 | GA | MEDICAID | 688965242E | 05 | GA | MEDICAID | 688965242G | 05 | GA | MEDICAID |