Basic Information
| Provider Information | |||||||||
| NPI: | 1003931965 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROBERT PATTERSON | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7396 | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278040396 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 114 STUART RD NE | ||||||||
| Address2: | #102 | ||||||||
| City: | CLEVELAND | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373124803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2529851371 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 07/03/2008 | ||||||||
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| AuthorizedOfficialLastName: | PATTERSON | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | OPTOMETRIST | ||||||||
| AuthorizedOfficialTelephone: | 2529851371 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1612 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 3941325 | 05 | TN | MEDICAID | 4125087 | 01 | TN | BCBS PROVIDER NUMBER | OTHER | P00258494 | 01 | TN | RAILROAD MEDICARE | OTHER |