=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972833564
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WALTER F. ANDERSON, MD, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2010
-----------------------------------------------------
Last Update Date | 01/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4675 N SHALLOWFORD RD SUITE 210
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30338-6309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-936-9403
-----------------------------------------------------
Fax | 770-936-9474
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4675 N SHALLOWFORD RD SUITE 210
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30338-6309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-936-9403
-----------------------------------------------------
Fax | 770-936-9474
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. WALTER FAUST ANDERSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 770-936-9403
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 021939
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------