1184677924 NPI number — ROBERT A. ROSSER MD

Table of content: ROBERT A. ROSSER MD (NPI 1184677924)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184677924 NPI number — ROBERT A. ROSSER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSSER
Provider First Name:
ROBERT
Provider Middle Name:
A.
Provider Name Prefix Text:
Provider Name Suffix Text:
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184677924
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGSPORT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37662-0009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-857-2093
Provider Business Mailing Address Fax Number:
423-390-3340

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 W STONE DR STE 2C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37660-3365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-378-7679
Provider Business Practice Location Address Fax Number:
423-378-7679
Provider Enumeration Date:
05/19/2006

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: 207RP1001X , with the licence number:  0101233222 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: 12584 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 006090656 . This is a "VIRGINIA MEDICAID" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 5824025 . This is a "AETNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 62134825604 . This is a "JOHN DEERE HEALTHCARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 64747850 . This is a "KENTUCKY MEDICAID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 100022749 . This is a "PHP TENN CARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1738771 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 055801 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 3180728 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0001676 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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