MEDICARE: CLIFFORD WILLIAM ROBERSON JR.

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	261Q00000X	Clinic/Center	22760	WV
2	207X00000X	Orthopaedic Surgery Physician	22760	WV

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659740066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLIFFORD WILLIAM ROBERSON JR.

Provider Business Mailing Address
First Line	:	3009 JACKSON AVE
Second Line	:
City	:	POINT PLEASANT
State	:	WV
Zip	:	25550-1717
Country	:	US
Telephone Number	:	304-675-8095
Fax Number	:	304-675-8096

Provider Business Practice Location Address
First Line	:	3009 JACKSON AVE
Second Line	:
City	:	POINT PLEASANT
State	:	WV
Zip	:	25550-1717
Country	:	US
Telephone Number	:	304-675-8095
Fax Number	:	304-675-8096

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CLIFFORD WILLIAM ROBERSON JR.
Credential	:	MD
Telephone Number	:	304-812-4182

Provider Enumeration Date	:	09/16/2015
Last Update Date	:	03/18/2016

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