Healthcare Provider Details

I. General information

NPI: 1538621453
Provider Name (Legal Business Name): ROBERT O BEVERIDGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2019
Last Update Date: 03/25/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2336 DAWSON RD STE 1500
ALBANY GA
31707-2802
US

IV. Provider business mailing address

500 W 3RD AVE STE 101
ALBANY GA
31701-1900
US

V. Phone/Fax

Practice location:
  • Phone: 229-312-8800
  • Fax: 229-312-8895
Mailing address:
  • Phone: 229-312-5802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number87394
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01087310A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: