Provider Demographics
NPI:1841858990
Name:ROBERTS, EDSEL JR (RN)
Entity type:Individual
Prefix:
First Name:EDSEL
Middle Name:
Last Name:ROBERTS
Suffix:JR
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 CRITTENDEN DR # 3518
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1885
Mailing Address - Country:US
Mailing Address - Phone:912-381-4038
Mailing Address - Fax:
Practice Address - Street 1:2310 CRITTENDEN DR # 3518
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1885
Practice Address - Country:US
Practice Address - Phone:912-381-4038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9375978163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine