Basic Information
| Provider Information | |||||||||
| NPI: | 1275576357 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | EGBERT | ||||||||
| MiddleName: | VERNON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 INDEPENDENCE PT | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647976044 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3911 S HIGHWAY 14 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296156138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642978890 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 01/02/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 6444 | SC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 064441 | 05 | SC | MEDICAID | 4556582 | 01 | SC | AETNA | OTHER | 1681141 | 01 | SC | CIGNA | OTHER | 57-1004971001 | 01 | SC | BCBS OF SC | OTHER |