Healthcare Provider Details

I. General information

NPI: 1093761884
Provider Name (Legal Business Name): JERRY M. ROBERTS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 02/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 SHAKERAG HL SUITE 201
PEACHTREE CITY GA
30269-4047
US

IV. Provider business mailing address

PO BOX 102321
ATLANTA GA
30368-2321
US

V. Phone/Fax

Practice location:
  • Phone: 770-486-7111
  • Fax: 770-486-7131
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number025657
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: