Provider Demographics
NPI:1508085911
Name:ANDERSON, PHILLIP RICHARD III (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:RICHARD
Last Name:ANDERSON
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 CELEBRATION PL STE 300
Mailing Address - Street 2:
Mailing Address - City:CELEBRATION
Mailing Address - State:FL
Mailing Address - Zip Code:34747-5434
Mailing Address - Country:US
Mailing Address - Phone:407-894-4474
Mailing Address - Fax:
Practice Address - Street 1:410 CELEBRATION PL
Practice Address - Street 2:
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-5433
Practice Address - Country:US
Practice Address - Phone:407-894-4474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME110072207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFD190ZMedicare PIN