Provider Demographics
NPI:1659740066
Name:CLIFFORD WILLIAM ROBERSON JR.
Entity Type:Organization
Organization Name:CLIFFORD WILLIAM ROBERSON JR.
Other - Org Name:ROBERSON ORTHOPEDIC CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLIFFORD
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:ROBERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:304-812-4182
Mailing Address - Street 1:3009 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:POINT PLEASANT
Mailing Address - State:WV
Mailing Address - Zip Code:25550-1717
Mailing Address - Country:US
Mailing Address - Phone:304-675-8095
Mailing Address - Fax:304-675-8096
Practice Address - Street 1:3009 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:POINT PLEASANT
Practice Address - State:WV
Practice Address - Zip Code:25550-1717
Practice Address - Country:US
Practice Address - Phone:304-675-8095
Practice Address - Fax:304-675-8096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-16
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22760207X00000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0143290Medicaid
WV3810009163Medicaid
OH2765459Medicaid
WV3910007237Medicaid
OH0143290Medicaid