Provider Demographics
NPI:1538526660
Name:BRILEY, ROBERT
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:BRILEY
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 1:7 PACKER PRIDE DR SE
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31788-7706
Mailing Address - Country:US
Mailing Address - Phone:912-536-0664
Mailing Address - Fax:
Practice Address - Street 1:3131 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6925
Practice Address - Country:US
Practice Address - Phone:229-985-3420
Practice Address - Fax:336-553-3994
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-20
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN201526367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered