Provider Demographics
NPI:1114563160
Name:RICHARD C ROBERTSON JR MD LLC
Entity Type:Organization
Organization Name:RICHARD C ROBERTSON JR MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:COVEY
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD207479
Authorized Official - Phone:601-212-8719
Mailing Address - Street 1:14 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-4433
Mailing Address - Country:US
Mailing Address - Phone:601-212-8719
Mailing Address - Fax:
Practice Address - Street 1:7039 HIGHWAY 190 EAST SERVICE RD STE C
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-4961
Practice Address - Country:US
Practice Address - Phone:985-869-8582
Practice Address - Fax:985-888-1838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1053756965OtherNPI