Provider Demographics
NPI:1881915932
Name:ROBERTSON, TIA
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:991 W HUDSON BLVD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-6430
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:991 W HUDSON BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-6430
Practice Address - Country:US
Practice Address - Phone:704-853-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-11
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-00934207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC2163Medicaid
NC1881915932Medicaid
NCNCJ052AMedicare PIN