Healthcare Provider Details

I. General information

NPI: 1194792390
Provider Name (Legal Business Name): ROBERT M ROBERSON III CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

247 S MAIN ST
REIDSVILLE GA
30453-4605
US

IV. Provider business mailing address

PO BOX 18824
GREENSBORO NC
27419-8824
US

V. Phone/Fax

Practice location:
  • Phone: 912-557-1000
  • Fax:
Mailing address:
  • Phone: 336-553-1659
  • Fax: 336-553-3994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN107179
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: