1508929134 NPI number — DR GEORGE T ROBERTS OPTOMETRIST PLLC

Table of content: (NPI 1508929134)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508929134 NPI number — DR GEORGE T ROBERTS OPTOMETRIST PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR GEORGE T ROBERTS OPTOMETRIST PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1508929134
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIDNEY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13838-1138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-563-7551
Provider Business Mailing Address Fax Number:
607-563-2442

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIDNEY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13838-1138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-563-7551
Provider Business Practice Location Address Fax Number:
607-563-2442
Provider Enumeration Date:
12/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROBERTS
Authorized Official First Name:
KATHI
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
607-563-7551

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  TUV003200 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02738127 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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