Provider Demographics
NPI:1740499946
Name:ROBERT B RAYBON ET AL PTR
Entity type:Organization
Organization Name:ROBERT B RAYBON ET AL PTR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:N
Authorized Official - Last Name:RAYBON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-282-7676
Mailing Address - Street 1:PO BOX 1033
Mailing Address - Street 2:
Mailing Address - City:TOCCOA
Mailing Address - State:GA
Mailing Address - Zip Code:30577-1417
Mailing Address - Country:US
Mailing Address - Phone:706-282-7676
Mailing Address - Fax:706-886-7280
Practice Address - Street 1:79 DOYLE ST
Practice Address - Street 2:
Practice Address - City:TOCCOA
Practice Address - State:GA
Practice Address - Zip Code:30577-6607
Practice Address - Country:US
Practice Address - Phone:706-282-7676
Practice Address - Fax:706-886-7280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207VG0400X, 207VX0000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3687Medicare ID - Type UnspecifiedMEDICARE GROUP ID