Basic Information
Provider Information | |||||||||
NPI: | 1699731026 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROBERTS | ||||||||
FirstName: | MARCUS | ||||||||
MiddleName: | CARROLL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 907 18TH ST E STE 400 | ||||||||
Address2: |   | ||||||||
City: | TIFTON | ||||||||
State: | GA | ||||||||
PostalCode: | 317943684 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2293533450 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2225 US HIGHWAY 41 N | ||||||||
Address2: |   | ||||||||
City: | TIFTON | ||||||||
State: | GA | ||||||||
PostalCode: | 317942749 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2293914100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/25/2006 | ||||||||
LastUpdateDate: | 03/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QH0002X | 035986 | GA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine | 207Q00000X | 35986 | GA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 000508791B | 05 | GA |   | MEDICAID | CL2838 | 01 |   | MEDICARE RAILROAD | OTHER |