Healthcare Provider Details

I. General information

NPI: 1962674176
Provider Name (Legal Business Name): BILLY EDWARD ROBERTS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2008
Last Update Date: 04/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 OCILLA RD STE A
DOUGLAS GA
31533-2207
US

IV. Provider business mailing address

1101 OCILLA ROAD STE A
DOUGLAS GA
31534-2207
US

V. Phone/Fax

Practice location:
  • Phone: 912-384-0600
  • Fax: 912-384-0601
Mailing address:
  • Phone: 912-384-1900
  • Fax: 912-383-5667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number000904
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: