Healthcare Provider Details

I. General information

NPI: 1942234117
Provider Name (Legal Business Name): ROBERT A. GANNAWAY, M.D., PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 E RAILROAD AVE SUITE B
CRYSTAL SPRINGS MS
39059-2520
US

IV. Provider business mailing address

408 E RAILROAD AVE SUITE B
CRYSTAL SPRINGS MS
39059-2520
US

V. Phone/Fax

Practice location:
  • Phone: 601-892-7860
  • Fax: 601-892-7861
Mailing address:
  • Phone: 601-892-7860
  • Fax: 601-892-7861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12331
License Number StateMS

VIII. Authorized Official

Name: DR. ROBERT A. GANNAWAY
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 601-892-7860