Provider Demographics
NPI:1073685418
Name:ANDERSON, MICHAEL GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GEORGE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:GEORGE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, PC
Mailing Address - Street 1:391 EAST MAIN STREET
Mailing Address - Street 2:HISTORIC HAWKINS BUILDING
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-2712
Mailing Address - Country:US
Mailing Address - Phone:770-720-6963
Mailing Address - Fax:770-720-6965
Practice Address - Street 1:391 EAST MAIN STREET
Practice Address - Street 2:HISTORIC HAWKINS BUILDING
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2712
Practice Address - Country:US
Practice Address - Phone:770-720-6963
Practice Address - Fax:770-720-6965
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054532208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA268736326AMedicaid
GA629697125AOtherMEDICAID PAYOR ID# EMPLOYER NORTHSIDE CHILDREN'S PEDIATRICS CTR, NPI# 1396945515
GA1609087972OtherAUTHORIZED CONTACT REPRESENTATIVE: STEPHANIE H. ANDERSON, NPI#
GA1609087972OtherAUTHORIZED CONTACT REPRESENTATIVE: STEPHANIE H. ANDERSON, NPI#