MEDICARE: MR. CARROLL BRACEY ROBERTSON III MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	9300298	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134154511
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CARROLL BRACEY ROBERTSON III MD

Provider Business Mailing Address
First Line	:	902B ROANOKE AVE
Second Line	:
City	:	ELIZABETH CITY
State	:	NC
Zip	:	27909-5565
Country	:	US
Telephone Number	:	252-384-0154
Fax Number	:	252-335-2731

Provider Business Practice Location Address
First Line	:	902B ROANOKE AVE
Second Line	:
City	:	ELIZABETH CITY
State	:	NC
Zip	:	27909-5565
Country	:	US
Telephone Number	:	252-384-0154
Fax Number	:	252-335-2731

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	03/06/2009

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