Provider Demographics
NPI:1578766671
Name:DR. RICHARD C. ANDERSON
Entity Type:Organization
Organization Name:DR. RICHARD C. ANDERSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:478-934-4763
Mailing Address - Street 1:PO BOX 494
Mailing Address - Street 2:
Mailing Address - City:COCHRAN
Mailing Address - State:GA
Mailing Address - Zip Code:31014-0494
Mailing Address - Country:US
Mailing Address - Phone:478-934-4763
Mailing Address - Fax:478-934-8080
Practice Address - Street 1:PO BOX 494
Practice Address - Street 2:
Practice Address - City:COCHRAN
Practice Address - State:GA
Practice Address - Zip Code:31014-0494
Practice Address - Country:US
Practice Address - Phone:478-934-4763
Practice Address - Fax:478-934-8080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA97901223G0001X
GARN126365 NP363LA2200X
GARN052713364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Not Answered364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00269123AMedicaid