Healthcare Provider Details

I. General information

NPI: 1750480174
Provider Name (Legal Business Name): JASON ANDREW ROBERTSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 11/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 MCCALLIE AVE
CHATTANOOGA TN
37404-3322
US

IV. Provider business mailing address

2415 MCCALLIE AVE
CHATTANOOGA TN
37404-3322
US

V. Phone/Fax

Practice location:
  • Phone: 423-624-2696
  • Fax: 423-697-2055
Mailing address:
  • Phone: 423-624-2696
  • Fax: 423-697-2055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number40189
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: