Provider Demographics
NPI:1609268077
Name:MILES C ANDERSON, MD
Entity Type:Organization
Organization Name:MILES C ANDERSON, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:MR
Authorized Official - First Name:MILES
Authorized Official - Middle Name:C
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-328-8358
Mailing Address - Street 1:530 ZEAGLER DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-6855
Mailing Address - Country:US
Mailing Address - Phone:386-328-8358
Mailing Address - Fax:386-325-0365
Practice Address - Street 1:530 ZEAGLER DR
Practice Address - Street 2:SUITE A
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-6855
Practice Address - Country:US
Practice Address - Phone:386-328-8358
Practice Address - Fax:386-325-0365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-23
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81063207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1164403689OtherINDIVIDUAL NPI
FL259553200Medicaid
FL35931Medicare PIN
FLH30068Medicare UPIN