Provider Demographics
NPI:1881791812
Name:RUSSELL SCOTT ANDERSON MD PA
Entity type:Organization
Organization Name:RUSSELL SCOTT ANDERSON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-479-1928
Mailing Address - Street 1:PO BOX 8580
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39303-8580
Mailing Address - Country:US
Mailing Address - Phone:601-479-1554
Mailing Address - Fax:601-564-0511
Practice Address - Street 1:1704 23RD AVENUE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301
Practice Address - Country:US
Practice Address - Phone:601-485-5081
Practice Address - Fax:601-485-5084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS133622085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00121517Medicaid
MS225866645BOtherBLUE CROSS BLUE SHIELD
E82196Medicare UPIN
MS00121517Medicaid