Healthcare Provider Details

I. General information

NPI: 1336035633
Provider Name (Legal Business Name): WILLIAM GLENN ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2025
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E BROAD ST
RICHMOND VA
23298-5025
US

IV. Provider business mailing address

1200 E BROAD ST BOX 980257
RICHMOND VA
23298-5025
US

V. Phone/Fax

Practice location:
  • Phone: 404-457-7458
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number0116041939
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: