Provider Demographics
NPI:1821066093
Name:PERRY, ROBERT T (PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:T
Last Name:PERRY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 737
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:GA
Mailing Address - Zip Code:31087-9753
Mailing Address - Country:US
Mailing Address - Phone:706-453-4945
Mailing Address - Fax:706-453-2954
Practice Address - Street 1:1041 PARK DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642-3465
Practice Address - Country:US
Practice Address - Phone:706-453-4945
Practice Address - Fax:706-453-2954
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001519207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAS59981Medicare UPIN