Healthcare Provider Details

I. General information

NPI: 1588047567
Provider Name (Legal Business Name): ROBERT WALLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2015
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

IV. Provider business mailing address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

V. Phone/Fax

Practice location:
  • Phone: 601-268-5650
  • Fax: 601-579-5240
Mailing address:
  • Phone: 601-268-5650
  • Fax: 601-579-5240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number30801
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberS8672
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: