Healthcare Provider Details

I. General information

NPI: 1134155310
Provider Name (Legal Business Name): MRS. ELLEN H ROBERTS IV
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3072 OLD PENDERGRASS RD
JEFFERSON GA
30549-7508
US

IV. Provider business mailing address

3072 OLD PENDERGRASS RD
JEFFERSON GA
30549-7508
US

V. Phone/Fax

Practice location:
  • Phone: 706-367-4377
  • Fax: 706-367-4377
Mailing address:
  • Phone: 706-367-4377
  • Fax: 706-367-4377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: