Healthcare Provider Details

I. General information

NPI: 1275565442
Provider Name (Legal Business Name): MARK A ROBERTS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 EDWINA STREET
EVERGREEN AL
36401
US

IV. Provider business mailing address

106 EDWINA STREET
EVERGREEN AL
36401
US

V. Phone/Fax

Practice location:
  • Phone: 251-578-4300
  • Fax: 251-578-4307
Mailing address:
  • Phone: 251-578-4300
  • Fax: 251-578-4307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number15010
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberPM.282
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15010
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: