Healthcare Provider Details

I. General information

NPI: 1871982173
Provider Name (Legal Business Name): ROBERT JESSIE RICHARDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2015
Last Update Date: 01/18/2021
Certification Date: 01/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 ROSS CLARK CIR
DOTHAN AL
36301-3022
US

IV. Provider business mailing address

5812 S STATE HIGHWAY 605
DOTHAN AL
36301-6514
US

V. Phone/Fax

Practice location:
  • Phone: 334-793-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-121895
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9464205
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: