Provider Demographics
NPI:1225534316
Name:LIBBY, ROBERT SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:SCOTT
Last Name:LIBBY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 COUNTRY CLUB DR STE 100
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-9069
Mailing Address - Country:US
Mailing Address - Phone:770-474-5281
Mailing Address - Fax:
Practice Address - Street 1:290 COUNTRY CLUB DR STE 100
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9069
Practice Address - Country:US
Practice Address - Phone:770-474-5281
Practice Address - Fax:770-389-8674
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA95847208800000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA95847OtherMEDICAL LICENSE