Healthcare Provider Details

I. General information

NPI: 1659740066
Provider Name (Legal Business Name): CLIFFORD WILLIAM ROBERSON JR.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2015
Last Update Date: 03/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 JACKSON AVE
POINT PLEASANT WV
25550-1717
US

IV. Provider business mailing address

3009 JACKSON AVE
POINT PLEASANT WV
25550-1717
US

V. Phone/Fax

Practice location:
  • Phone: 304-675-8095
  • Fax: 304-675-8096
Mailing address:
  • Phone: 304-675-8095
  • Fax: 304-675-8096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number22760
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number22760
License Number StateWV

VIII. Authorized Official

Name: DR. CLIFFORD WILLIAM ROBERSON JR.
Title or Position: OWNER
Credential: MD
Phone: 304-812-4182