Provider Demographics
NPI:1477780708
Name:KIRTLEY, ROBERT GLENN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GLENN
Last Name:KIRTLEY
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 1:101 W NORTHSIDE DR # F
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1714
Mailing Address - Country:US
Mailing Address - Phone:229-262-1981
Mailing Address - Fax:229-375-0392
Practice Address - Street 1:101 W NORTHSIDE DR # F
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1714
Practice Address - Country:US
Practice Address - Phone:229-262-1981
Practice Address - Fax:229-375-0392
Is Sole Proprietor?:No
Enumeration Date:2009-06-12
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA82327208100000X
IN01069431A208D00000X, 208100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003220961CMedicaid