Provider Demographics
NPI:1477612414
Name:LARRY W ANDERSON, DO, LLC
Entity Type:Organization
Organization Name:LARRY W ANDERSON, DO, LLC
Other - Org Name:ANDERSON FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:706-265-1335
Mailing Address - Street 1:6002 HIGHWAY 53 E
Mailing Address - Street 2:
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-6227
Mailing Address - Country:US
Mailing Address - Phone:706-265-1335
Mailing Address - Fax:706-265-2296
Practice Address - Street 1:6002 HIGHWAY 53 E
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-6227
Practice Address - Country:US
Practice Address - Phone:706-265-1335
Practice Address - Fax:706-265-2296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020648207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GRP7339OtherMEDICARE LEGACY
GADG1560OtherRAILROAD MEDICARE GRP #
GADG1560OtherRAILROAD MEDICARE GRP #