Basic Information
| Provider Information | |||||||||
| NPI: | 1538621453 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEVERIDGE | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | O | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 W 3RD AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317011900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293125802 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2336 DAWSON RD STE 1500 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317072802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293128800 | ||||||||
| FaxNumber: | 2293128895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2019 | ||||||||
| LastUpdateDate: | 03/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 87394 | GA | N | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | GA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 01087310A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.