Provider Demographics
NPI:1649227745
Name:GANNAWAY, ROBERT A (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:GANNAWAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ROBERT
Other - Middle Name:A
Other - Last Name:GANNAWAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, PLLC
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12331207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01529794Medicaid
201944354OtherTIN
EO2939Medicare UPIN
201944354OtherTIN