Healthcare Provider Details

I. General information

NPI: 1790103232
Provider Name (Legal Business Name): ROBERT BEESBURG, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 04/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 SALUDA POINTE DR
LEXINGTON SC
29072-7295
US

IV. Provider business mailing address

PO BOX 681
COLUMBIA SC
29202-0681
US

V. Phone/Fax

Practice location:
  • Phone: 803-765-1838
  • Fax:
Mailing address:
  • Phone: 803-765-1838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number16948
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number16948
License Number StateSC

VIII. Authorized Official

Name: ROBERT Y. BEESBURG JR.
Title or Position: OWNER
Credential: MD
Phone: 803-312-2591