Healthcare Provider Details

I. General information

NPI: 1760798227
Provider Name (Legal Business Name): ANDERSON PHYSICIAN ALLIANCE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2010
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2124 14TH ST
MERIDIAN MS
39301-4040
US

IV. Provider business mailing address

PO BOX 2839
MERIDIAN MS
39302-2839
US

V. Phone/Fax

Practice location:
  • Phone: 601-703-3480
  • Fax: 601-703-0124
Mailing address:
  • Phone: 601-703-3480
  • Fax: 601-703-0124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateMS

VIII. Authorized Official

Name: GREGORY M DUCKETT
Title or Position: SR VP / CLO
Credential:
Phone: 901-227-5233