Basic Information
| Provider Information | |||||||||
| NPI: | 1760798227 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANDERSON PHYSICIAN ALLIANCE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2839 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393022839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017033480 | ||||||||
| FaxNumber: | 6017030124 | ||||||||
| Practice Location | |||||||||
| Address1: | 2124 14TH ST | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393014040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017033480 | ||||||||
| FaxNumber: | 6017030124 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2010 | ||||||||
| LastUpdateDate: | 06/16/2015 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6017035010 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QM1300X | MS | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 127195 | 05 | AL | MEDICAID | 03604849 | 05 | MS | MEDICAID |