Provider Demographics
NPI:1245297183
Name:COLEMAN, ROBERT (CRNA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 235019
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36123-5019
Mailing Address - Country:US
Mailing Address - Phone:334-279-1450
Mailing Address - Fax:334-279-1660
Practice Address - Street 1:1400 E UNION ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-3246
Practice Address - Country:US
Practice Address - Phone:662-378-3783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR542965367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS201397813AOtherBCBS
MS00015861Medicaid
MS430002070Medicare ID - Type Unspecified
MSR29113Medicare UPIN