Provider Demographics
NPI:1720290869
Name:WILLIS REID ROBERTS, JR.
Entity Type:Organization
Organization Name:WILLIS REID ROBERTS, JR.
Other - Org Name:W. REID ROBERTS, JR., M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BOBBIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:478-453-0662
Mailing Address - Street 1:641 W THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-2337
Mailing Address - Country:US
Mailing Address - Phone:478-453-0662
Mailing Address - Fax:478-452-8067
Practice Address - Street 1:641 W THOMAS ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2337
Practice Address - Country:US
Practice Address - Phone:478-453-0662
Practice Address - Fax:478-452-8067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045116207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA045116OtherGEORGIA MEDICAL LICENSE
GA00826999BMedicaid
GA52702166OtherBCBS OF GA
GA00826999BMedicaid
GA045116OtherGEORGIA MEDICAL LICENSE
GA=========OtherTIN
GAG98520Medicare UPIN
GA52702166OtherBCBS OF GA
GA=========OtherTIN
GA110208084Medicare ID - Type UnspecifiedRAILROAD MEDICARE