MEDICARE: DR. ROBERT THOMAS DAMBACH JR. D.O.

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	207R00000X	Internal Medicine Physician	030039	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	52022005	OTHER	GA	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1538161252
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT THOMAS DAMBACH JR. D.O.

Provider Business Mailing Address
First Line	:	4720 NELSON BROGDON BLVD
Second Line	:
City	:	SUGARHILL
State	:	GA
Zip	:	30518-3480
Country	:	US
Telephone Number	:	770-945-1990
Fax Number	:	770-945-3631

Provider Business Practice Location Address
First Line	:	4720 NELSON BROGDON BLVD
Second Line	:
City	:	SUGARHILL
State	:	GA
Zip	:	30518-3480
Country	:	US
Telephone Number	:	770-945-1990
Fax Number	:	770-945-3631

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

Provider Enumeration Date	:	08/12/2005
Last Update Date	:	10/08/2007

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Directions to “ DR. ROBERT THOMAS DAMBACH JR. D.O.” Practice Location

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