Individual
RUSSELL ROBERTS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
255 W 5TH ST SW, SUITE 150, ROME, GA 30165-2817
(706) 232-1545
(706) 232-3819
Mailing address
PO BOX 369, ROME, GA 30162-0369
(706) 291-2077
(706) 235-4177
Taxonomy
Speciality
Code
Description
License number
State
2085B0100X
Body Imaging Physician
055958
GA
2085N0700X
Neuroradiology Physician
055958
GA
2085N0904X
Nuclear Radiology Physician
055958
GA
2085P0229X
Pediatric Radiology Physician
055958
GA
2085R0202X
Diagnostic Radiology Physician
Primary
055958
GA
2085R0203X
Therapeutic Radiology Physician
055958
GA
2085R0204X
Vascular & Interventional Radiology Physician
055958
GA
2085U0001X
Diagnostic Ultrasound Physician
055958
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
326530183A
—
GA
01
—
393121
BCBS OF GA
GA
01
—
581088318A
MEDICARE GROUP PROVIDER #
GA
01
—
P00250939
RAILROAD MEDICARE
GA
Enumeration date
10/19/2006
Last updated
10/28/2016
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