1578593620 NPI number — DR. PHILIP L ROBERTS MD

Table of content: DR. PHILIP L ROBERTS MD (NPI 1578593620)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578593620 NPI number — DR. PHILIP L ROBERTS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTS
Provider First Name:
PHILIP
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
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:
1578593620
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 682985
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRANKLIN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37068-2985
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-972-9700
Provider Business Mailing Address Fax Number:
615-369-6340

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
529 CAPP HARLAN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOMPKINSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42167-1808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-487-9231
Provider Business Practice Location Address Fax Number:
270-487-5784
Provider Enumeration Date:
07/04/2006

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: 207P00000X , with the licence number:  23857 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2083P0901X , with the licence number: 23857 , 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: 009977130 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64249790 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000204367 . This is a "BCBS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 4029412 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1804660000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3838848 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3072989 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2273070 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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