Healthcare Provider Details

I. General information

NPI: 1841858990
Provider Name (Legal Business Name): EDSEL ROBERTS JR. RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2019
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 CRITTENDEN DR # 3518
LOUISVILLE KY
40217-1885
US

IV. Provider business mailing address

2310 CRITTENDEN DR # 3518
LOUISVILLE KY
40217-1885
US

V. Phone/Fax

Practice location:
  • Phone: 912-381-4038
  • Fax:
Mailing address:
  • Phone: 912-381-4038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN9375978
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: