Provider Demographics
NPI:1396732657
Name:TALLEY, ROY LAMAR JR (MD)
Entity type:Individual
Prefix:DR
First Name:ROY
Middle Name:LAMAR
Last Name:TALLEY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:R
Other - Middle Name:L
Other - Last Name:TALLEY
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1301 SIGMAN RD NE
Mailing Address - Street 2:STE 100
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-3812
Mailing Address - Country:US
Mailing Address - Phone:770-760-9360
Mailing Address - Fax:770-760-9303
Practice Address - Street 1:1301 SIGMAN RD NE
Practice Address - Street 2:SUITE 100
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012
Practice Address - Country:US
Practice Address - Phone:770-760-9360
Practice Address - Fax:770-760-9303
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA29957207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000357486FMedicaid
GA05BDBGMMedicare PIN
GAD41204Medicare UPIN