Basic Information
| Provider Information | |||||||||
| NPI: | 1285662486 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LANDRUM | ||||||||
| FirstName: | BOBBY | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8147 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319088147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063202773 | ||||||||
| FaxNumber: | 7065964226 | ||||||||
| Practice Location | |||||||||
| Address1: | 2122 MANCHESTER EXPRESSWAY | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063202773 | ||||||||
| FaxNumber: | 7065964226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 07/30/2015 | ||||||||
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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 | 363LA2100X | 1066794 | AL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2200X | 1066794 | AL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | RN109950 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 003104894C | 05 | GA | MEDICAID | 159805 | 05 | AL | MEDICAID |