Provider Demographics
NPI:1942234117
Name:ROBERT A. GANNAWAY, M.D., PLLC
Entity Type:Organization
Organization Name:ROBERT A. GANNAWAY, M.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:GANNAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-892-7860
Mailing Address - Street 1:408 E RAILROAD AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:CRYSTAL SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39059-2520
Mailing Address - Country:US
Mailing Address - Phone:601-892-7860
Mailing Address - Fax:601-892-7861
Practice Address - Street 1:408 E RAILROAD AVE
Practice Address - Street 2:SUITE B
Practice Address - City:CRYSTAL SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39059-2520
Practice Address - Country:US
Practice Address - Phone:601-892-7860
Practice Address - Fax:601-892-7861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12331207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01529794Medicaid
=========OtherTIN
EO2939Medicare UPIN
C03236Medicare ID - Type Unspecified