Basic Information
| Provider Information | |||||||||
| NPI: | 1497070312 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTSON | ||||||||
| FirstName: | HESS | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROBERTSON | ||||||||
| OtherFirstName: | HESS | ||||||||
| OtherMiddleName: | MCCLELLAN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2500 NORTH STATE STREET | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018151196 | ||||||||
| FaxNumber: | 6019845939 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 NORTH STATE STREET | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018151196 | ||||||||
| FaxNumber: | 6019845939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2010 | ||||||||
| LastUpdateDate: | 08/29/2018 | ||||||||
| 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 | 207L00000X | 35.125205 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 24322 | MS | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LC0200X | 24322 | MS | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 192054 | 05 | AL | MEDICAID | 09909850 | 05 | MS | MEDICAID |