Provider Demographics
NPI:1467596031
Name:ROBERTS, ANNE A
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:A
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 GEORGETOWN ST
Mailing Address - Street 2:
Mailing Address - City:HAZLEHURST
Mailing Address - State:MS
Mailing Address - Zip Code:39083-2501
Mailing Address - Country:US
Mailing Address - Phone:601-894-2271
Mailing Address - Fax:
Practice Address - Street 1:640 GEORGETOWN ST
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:MS
Practice Address - Zip Code:39083-2501
Practice Address - Country:US
Practice Address - Phone:601-894-2271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS077052083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123681Medicaid
MSE05455Medicare UPIN