MEDICARE: DR. ROBERD MANER BOSTICK M.D.

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	057435	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	31896	OTHER	MN	STATE MED. LIC. NO.
2	9401136	OTHER	NC	STATE MED. LIC. NO.
3	057435	OTHER	GA	STATE MED. LIC. NO.
4	8373	OTHER	SC	STATE MED. LIC. NO.

General Provider Information

NPI Number	:	1194934703
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERD MANER BOSTICK M.D.

Provider Business Mailing Address
First Line	:	OF EPIDEMIOLOGY
Second Line	:	1518 CLIFTON ROAD NE
City	:	ATLANTA
State	:	GA
Zip	:	30322-4201
Country	:	US
Telephone Number	:	404-727-2671
Fax Number	:	404-727-8737

Provider Business Practice Location Address
First Line	:	OF EPIDEMIOLOGY
Second Line	:	1518 CLIFTON ROAD NE
City	:	ATLANTA
State	:	GA
Zip	:	30322-4201
Country	:	US
Telephone Number	:	404-727-2671
Fax Number	:	404-727-8737

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

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	03/07/2023

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