Provider Demographics
NPI:1992021083
Name:TAYLOR, ROBERT B JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:B
Last Name:TAYLOR
Suffix:JR
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 1:111 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4157
Mailing Address - Country:US
Mailing Address - Phone:706-845-3544
Mailing Address - Fax:706-812-2361
Practice Address - Street 1:111 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4157
Practice Address - Country:US
Practice Address - Phone:706-845-3544
Practice Address - Fax:706-812-2361
Is Sole Proprietor?:No
Enumeration Date:2010-04-14
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC164985207R00000X
GA73859207RH0000X, 207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003161717AMedicaid
GA202I927580Medicare PIN