Provider Demographics
NPI:1124175146
Name:ANDERSON, ALAN RANDALL (MD)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:RANDALL
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8611
Mailing Address - Fax:
Practice Address - Street 1:900 W FARIS RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4255
Practice Address - Country:US
Practice Address - Phone:864-455-8898
Practice Address - Fax:864-241-9237
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0550842080P0207X
SC247832080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC576007863054OtherBCBS
SC247833Medicaid
SCAA21507951Medicare PIN
SCAA21503640Medicare PIN