MEDICARE: MR. JAMES CLIFTON ROBERSON III CRNA

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	367500000X	Certified Registered Nurse Anesthetist	R045040	ME
2	367500000X	Certified Registered Nurse Anesthetist	523406	NY

General Provider Information

NPI Number	:	1508816497
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES CLIFTON ROBERSON III CRNA

Provider Business Mailing Address
First Line	:	76 PINEHURST AVE APT 5
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10033-4510
Country	:	US
Telephone Number	:	207-400-9759
Fax Number	:

Provider Business Practice Location Address
First Line	:	617 W 168TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10032-3703
Country	:	US
Telephone Number	:	212-305-4196
Fax Number	:

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

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	09/11/2012

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