1821046715 NPI number — DR. CLIFFORD WILLIAM ROBERSON JR. MD

Table of content: (NPI 1104890755)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821046715 NPI number — DR. CLIFFORD WILLIAM ROBERSON JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERSON
Provider First Name:
CLIFFORD
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROBERSON
Provider Other First Name:
CLIFFORD
Provider Other Middle Name:
W
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
JR.
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1821046715
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3009 JACKSON AVE
Provider Second Line Business Mailing Address:
PO BOX 601
Provider Business Mailing Address City Name:
POINT PLEASANT
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25550-1717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-675-8095
Provider Business Mailing Address Fax Number:
304-675-8096

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3009 JACKSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POINT PLEASANT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25550-1717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-675-8095
Provider Business Practice Location Address Fax Number:
304-675-8096
Provider Enumeration Date:
05/04/2006

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: 207XS0117X , with the licence number:  22760 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3910007237 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0143290 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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