Provider Demographics
NPI:1679663611
Name:ROBESON MEDICAL CLINIC
Entity Type:Organization
Organization Name:ROBESON MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SANDHYA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:THOMAS-MONTILUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-738-2330
Mailing Address - Street 1:1750 METROMEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3861
Mailing Address - Country:US
Mailing Address - Phone:910-223-3123
Mailing Address - Fax:910-223-3122
Practice Address - Street 1:1750 METROMEDICAL DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3861
Practice Address - Country:US
Practice Address - Phone:910-223-3123
Practice Address - Fax:910-223-3122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89-0226CMedicaid
NC2323228Medicare ID - Type Unspecified
NC89-0226CMedicaid