Basic Information
Provider Information | |||||||||
NPI: | 1003896325 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROBERTSON | ||||||||
FirstName: | HOWARD | ||||||||
MiddleName: | MASON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ROBERTSON | ||||||||
OtherFirstName: | HOWARD | ||||||||
OtherMiddleName: | MASON | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 2006 FRANKLIN ST SE | ||||||||
Address2: | SUITE 301 | ||||||||
City: | HUNTSVILLE | ||||||||
State: | AL | ||||||||
PostalCode: | 358014551 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2565399471 | ||||||||
FaxNumber: | 2565399472 | ||||||||
Practice Location | |||||||||
Address1: | 101 SIVLEY RD SW | ||||||||
Address2: |   | ||||||||
City: | HUNTSVILLE | ||||||||
State: | AL | ||||||||
PostalCode: | 358014421 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2562651000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/20/2006 | ||||||||
LastUpdateDate: | 09/04/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 00012680 | AL | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 208D00000X | 12680 | AL | N |   | Allopathic & Osteopathic Physicians | General Practice |   |
ID Information
ID | Type | State | Issuer | Description | 000024079 | 05 | AL |   | MEDICAID | 009975805 | 05 | AL |   | MEDICAID | 51000010 | 01 | AL | BCBS MADISON SURG CTR | OTHER | 3074889 | 01 | TN | BCBS TN | OTHER | 51024079 | 01 | AL | BCBS AL | OTHER |