Healthcare Provider Details

I. General information

NPI: 1790750065
Provider Name (Legal Business Name): LEE DOUGLASS ROBERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 BAPTIST BLVD STE 405
COLUMBUS MS
39705-2004
US

IV. Provider business mailing address

PO BOX 405827
ATLANTA GA
30384-5827
US

V. Phone/Fax

Practice location:
  • Phone: 662-244-2288
  • Fax: 662-244-2289
Mailing address:
  • Phone: 901-226-3186
  • Fax: 901-226-3160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number14609
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: