Basic Information
| Provider Information | |||||||||
| NPI: | 1720064595 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLDBLATT | ||||||||
| FirstName: | ROY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5779 | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306045779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063100381 | ||||||||
| FaxNumber: | 7063100390 | ||||||||
| Practice Location | |||||||||
| Address1: | 5126 HOSPITAL DR NE | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300142566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005326151 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 07/21/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 31005 | GA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000409901N | 05 | GA | MEDICAID |