Basic Information
| Provider Information | |||||||||
| NPI: | 1841372828 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PU | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 20452 | ||||||||
| Address2: | PSMG-CRED | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432200452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144422406 | ||||||||
| FaxNumber: | 6144422410 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 GRESHAM DR | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235071904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573883221 | ||||||||
| FaxNumber: | 7573883799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 09/30/2014 | ||||||||
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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 | 207ZP0101X | 0101243228 | VA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 207ZC0500X | 0101243228 | VA | N | Allopathic & Osteopathic Physicians | Pathology | Cytopathology |
ID Information
| ID | Type | State | Issuer | Description | 1841372828 | 05 | VA | MEDICAID | 5909889 | 05 | NC | MEDICAID |