Healthcare Provider Details

I. General information

NPI: 1053321513
Provider Name (Legal Business Name): ROBERTO SPRINGER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 05/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 7TH ST BLDG 700700-A 78 MDG/XXX
ROBINS AFB GA
31098-2227
US

IV. Provider business mailing address

1021 CHESTNUT LN RD
ATHENS GA
30606-6214
US

V. Phone/Fax

Practice location:
  • Phone: 706-372-6102
  • Fax: 706-372-6102
Mailing address:
  • Phone: 706-372-6102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003709
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number003709
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: