Provider Demographics
NPI:1790456036
Name:ANDERSON, BENJAMIN CHARLES FOX (PA)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:CHARLES FOX
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2532 N DECATUR RD APT 1221
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-6142
Mailing Address - Country:US
Mailing Address - Phone:530-401-5395
Mailing Address - Fax:
Practice Address - Street 1:275 COLLIER RD NW STE 300
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1740
Practice Address - Country:US
Practice Address - Phone:404-350-0009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-27
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11471207RP1001X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease