1225075815 NPI number — JOE SAM ROBINSON JR.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225075815 NPI number — JOE SAM ROBINSON JR.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBINSON
Provider First Name:
JOE
Provider Middle Name:
SAM
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROBINSON
Provider Other First Name:
JOE
Provider Other Middle Name:
SAM
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
JR.
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1225075815
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
840 PINE STREET
Provider Second Line Business Mailing Address:
SUITE 880
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31201-1717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-743-7092
Provider Business Mailing Address Fax Number:
478-743-6293

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
840 PINE ST
Provider Second Line Business Practice Location Address:
SUITE 880
Provider Business Practice Location Address City Name:
MACON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31201-2100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-743-7092
Provider Business Practice Location Address Fax Number:
478-743-6293
Provider Enumeration Date:
06/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  022465 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207T00000X , with the licence number: 022465 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00232075A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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