Basic Information
Provider Information | |||||||||
NPI: | 1033119128 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRAND | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | III | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 14039 | ||||||||
Address2: |   | ||||||||
City: | AUGUSTA | ||||||||
State: | GA | ||||||||
PostalCode: | 309190039 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7068639797 | ||||||||
FaxNumber: | 7068607686 | ||||||||
Practice Location | |||||||||
Address1: | 3650 J DEWEY GRAY CR | ||||||||
Address2: |   | ||||||||
City: | AUGUSTA | ||||||||
State: | GA | ||||||||
PostalCode: | 30909 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7068639797 | ||||||||
FaxNumber: | 7068607686 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/29/2005 | ||||||||
LastUpdateDate: | 04/13/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 12427 | GA | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 009601010 | 05 | AL |   | MEDICAID | 00007917A | 05 | GA |   | MEDICAID | 0519782 | 01 | GA | AETNA | OTHER | 201603825 | 01 | GA | RAILROAD MEDICARE | OTHER | 581327528 | 01 | GA | COMMERICAL | OTHER | G12427 | 05 | SC |   | MEDICAID | 0900120 | 01 | GA | UNITED HEALTHCARE | OTHER | 175569 | 01 | GA | BCBS | OTHER |