MEDICARE: DR. BRUCE E ROBERTS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	09179	MS
2	207P00000X	Emergency Medicine Physician	09179	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C48217	OTHER	MS	DR

General Provider Information

NPI Number	:	1770570038
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRUCE E ROBERTS M.D.

Provider Business Mailing Address
First Line	:	5345 HIGHWAY 18 W
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39209-9421
Country	:	US
Telephone Number	:	601-924-5007
Fax Number	:	601-923-9921

Provider Business Practice Location Address
First Line	:	5345 HIGHWAY 18 W
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39209-9421
Country	:	US
Telephone Number	:	601-924-5007
Fax Number	:	601-923-9921

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2005
Last Update Date	:	01/28/2008

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