Provider Demographics
NPI:1821048794
Name:HARGRAVES, ROBERT W (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:W
Last Name:HARGRAVES
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 1:180 GREYSTONE PASS
Mailing Address - Street 2:
Mailing Address - City:GUNTERSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35976-4801
Mailing Address - Country:US
Mailing Address - Phone:256-224-9167
Mailing Address - Fax:256-486-9244
Practice Address - Street 1:180 GREYSTONE PASS
Practice Address - Street 2:
Practice Address - City:GUNTERSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35976-4801
Practice Address - Country:US
Practice Address - Phone:256-224-9167
Practice Address - Fax:256-486-9244
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2021-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9277207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051011175OtherBCBS OF AL
AL000011175Medicaid