Basic Information
| Provider Information | |||||||||
| NPI: | 1811958309 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RODGERS | ||||||||
| FirstName: | ROBIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2016 | ||||||||
| Address2: | |||||||||
| City: | CARTERSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301201684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703820185 | ||||||||
| FaxNumber: | 7703820247 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 FOX CHASE | ||||||||
| Address2: | |||||||||
| City: | CARTERSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301202491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703820185 | ||||||||
| FaxNumber: | 7703820247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2006 | ||||||||
| LastUpdateDate: | 11/03/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 035316 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00529878B | 05 | GA | MEDICAID |