Provider Demographics
NPI:1871561274
Name:ROSEBERRY, ROBERT LEE
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:LEE
Last Name:ROSEBERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 PARK CIR
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-8012
Mailing Address - Country:US
Mailing Address - Phone:843-815-3190
Mailing Address - Fax:
Practice Address - Street 1:1 PINCKNEY BLVD
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-6122
Practice Address - Country:US
Practice Address - Phone:843-228-3633
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman