Provider Demographics
NPI:1164515839
Name:DR. MICHAEL B. ROBERTS, MD, GENERAL & THORACIC SURGERY, PC
Entity Type:Organization
Organization Name:DR. MICHAEL B. ROBERTS, MD, GENERAL & THORACIC SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-452-0205
Mailing Address - Street 1:750 N COBB ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-2390
Mailing Address - Country:US
Mailing Address - Phone:478-452-0205
Mailing Address - Fax:478-452-0307
Practice Address - Street 1:750 N COBB ST
Practice Address - Street 2:SUITE 110
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2390
Practice Address - Country:US
Practice Address - Phone:478-452-0205
Practice Address - Fax:478-452-0307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA026367.174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00425598AMedicaid
GABR2165632OtherDEA NUMBER
GABR2165632OtherDEA NUMBER
GA00425598AMedicaid