Provider Demographics
NPI:1285662486
Name:LANDRUM, BOBBY G (NP)
Entity Type:Individual
Prefix:MR
First Name:BOBBY
Middle Name:G
Last Name:LANDRUM
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8147
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31908-8147
Mailing Address - Country:US
Mailing Address - Phone:706-320-2773
Mailing Address - Fax:706-596-4226
Practice Address - Street 1:2122 MANCHESTER EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904
Practice Address - Country:US
Practice Address - Phone:706-320-2773
Practice Address - Fax:706-596-4226
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1066794363LA2100X, 363LA2200X
GARN109950363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003104894CMedicaid
AL159805Medicaid
GA202I504644Medicare PIN
202I50137OtherMEDICARE
AL529801770Medicaid
S59057Medicare UPIN