Healthcare Provider Details

I. General information

NPI: 1285662486
Provider Name (Legal Business Name): BOBBY G LANDRUM NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2122 MANCHESTER EXPRESSWAY
COLUMBUS GA
31904
US

IV. Provider business mailing address

PO BOX 8147
COLUMBUS GA
31908-8147
US

V. Phone/Fax

Practice location:
  • Phone: 706-320-2773
  • Fax: 706-596-4226
Mailing address:
  • Phone: 706-320-2773
  • Fax: 706-596-4226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1066794
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number1066794
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN109950
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: