Provider Demographics
NPI:1184880221
Name:EBERLY, ROBERT SHANE (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:SHANE
Last Name:EBERLY
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 1:100 BREWSTER BLVD
Mailing Address - Street 2:
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28547-2575
Mailing Address - Country:US
Mailing Address - Phone:910-540-4300
Mailing Address - Fax:
Practice Address - Street 1:BRANCH MEDICAL CLINIC HANSEN
Practice Address - Street 2:BLDG 2384
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96384-0068
Practice Address - Country:US
Practice Address - Phone:619-261-7754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-29
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101244243207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101244243OtherSTATE LICENSE NUMBER