Provider Demographics
NPI:1811947443
Name:ANDERSON, HENRY HARRISON IV (MD)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:HARRISON
Last Name:ANDERSON
Suffix:IV
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 1:2795 MAIN ST W
Mailing Address - Street 2:BLDG 19B
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-3164
Mailing Address - Country:US
Mailing Address - Phone:678-252-2137
Mailing Address - Fax:678-336-7099
Practice Address - Street 1:5530B OLD NATIONAL HWY
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-3344
Practice Address - Country:US
Practice Address - Phone:404-766-6001
Practice Address - Fax:678-336-7099
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033792207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000477309QMedicaid
GA000477309RMedicaid
GA000477309RMedicaid
GAF01680Medicare UPIN
GA08BDJHD02Medicare ID - Type Unspecified