Provider Demographics
NPI:1891814604
Name:ANDERSON, GREGORY (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
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:PO BOX 39
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-0001
Mailing Address - Country:US
Mailing Address - Phone:662-536-1020
Mailing Address - Fax:662-536-1024
Practice Address - Street 1:2831 AIRWAYS BLVD
Practice Address - Street 2:BLDG A STE 102
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38132-1106
Practice Address - Country:US
Practice Address - Phone:901-348-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN252582083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine