Provider Demographics
NPI:1922115765
Name:ANDERSON, CARMELLA (MD)
Entity Type:Individual
Prefix:DR
First Name:CARMELLA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
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:PO BOX 2495
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35403-2495
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:907A 31ST ST E
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35405-2507
Practice Address - Country:US
Practice Address - Phone:205-633-3900
Practice Address - Fax:205-633-3848
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14587207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000087440Medicaid
AL87440OtherBCBS OF AL
AL87440OtherBCBS OF AL
AL87440OtherBCBS OF AL
AL63-1069962OtherTAX ID NUMBER