Provider Demographics
NPI:1003830563
Name:ADAMS, ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:ADAMS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2064
Mailing Address - Country:US
Mailing Address - Phone:601-968-1000
Mailing Address - Fax:
Practice Address - Street 1:1600 N STATE ST
Practice Address - Street 2:STE 400
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1689
Practice Address - Country:US
Practice Address - Phone:601-944-1717
Practice Address - Fax:601-944-9780
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS41677103T00000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03731341Medicaid
MS680000262Medicare ID - Type Unspecified