Provider Demographics
NPI:1942076195
Name:ANDERSON, MELVIN M III
Entity Type:Individual
Prefix:MR
First Name:MELVIN
Middle Name:M
Last Name:ANDERSON
Suffix:III
Gender:M
Credentials:
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 124
Mailing Address - Street 2:
Mailing Address - City:PORT GIBSON
Mailing Address - State:MS
Mailing Address - Zip Code:39150-0124
Mailing Address - Country:US
Mailing Address - Phone:601-618-3728
Mailing Address - Fax:
Practice Address - Street 1:507 MARKET ST
Practice Address - Street 2:
Practice Address - City:PORT GIBSON
Practice Address - State:MS
Practice Address - Zip Code:39150-2041
Practice Address - Country:US
Practice Address - Phone:601-618-3728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X, 251300000X, 374U00000X, 376J00000X, 385H00000X, 251X00000X
MS374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage
No171000000XOther Service ProvidersMilitary Health Care Provider
No251300000XAgenciesLocal Education Agency (LEA)
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
No385H00000XRespite Care FacilityRespite Care