Provider Demographics
NPI:1972603132
Name:ROBESON MEDICAL CLINIC PC
Entity Type:Organization
Organization Name:ROBESON MEDICAL CLINIC PC
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:THOMASMONTILUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-738-2330
Mailing Address - Street 1:4320 FAYETTEVILLE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-2706
Mailing Address - Country:US
Mailing Address - Phone:910-738-2330
Mailing Address - Fax:910-738-1403
Practice Address - Street 1:4320 FAYETTEVILLE RD
Practice Address - Street 2:SUITE A
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2706
Practice Address - Country:US
Practice Address - Phone:910-738-2330
Practice Address - Fax:910-738-1403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9701618207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89-0226CMedicaid
NC0226COtherBC/BS PROVIDER #
NC2323228Medicare PIN
NC89-0226CMedicaid