Provider Demographics
NPI:1982061677
Name:MEDEARIS, ROBERT SCOTT (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:SCOTT
Last Name:MEDEARIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1824 WALTON WAY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-3804
Mailing Address - Country:US
Mailing Address - Phone:706-737-9250
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH STREET, BIW 2144
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912
Practice Address - Country:US
Practice Address - Phone:706-721-4544
Practice Address - Fax:706-446-0077
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-26
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA80214207L00000X
GA6924207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty