Provider Demographics
NPI:1386639136
Name:ANDERSON, MARY ELISABETH NEAL (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELISABETH NEAL
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:NEAL
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38302-0400
Mailing Address - Country:US
Mailing Address - Phone:731-425-5752
Mailing Address - Fax:731-425-5783
Practice Address - Street 1:2863 HIGHWAY 45 BYP
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3618
Practice Address - Country:US
Practice Address - Phone:731-664-1375
Practice Address - Fax:731-660-8336
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28500208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3805899Medicaid
TN3805899Medicare PIN
TN3805899Medicaid
TNG46433Medicare UPIN