Healthcare Provider Details

I. General information

NPI: 1477780708
Provider Name (Legal Business Name): ROBERT GLENN KIRTLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2009
Last Update Date: 07/13/2020
Certification Date: 07/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W NORTHSIDE DR # F
VALDOSTA GA
31602-1714
US

IV. Provider business mailing address

101 W NORTHSIDE DR # F
VALDOSTA GA
31602-1714
US

V. Phone/Fax

Practice location:
  • Phone: 229-262-1981
  • Fax: 229-375-0392
Mailing address:
  • Phone: 229-262-1981
  • Fax: 229-375-0392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number82327
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number01069431A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number01069431A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: