Provider Demographics
NPI:1669623260
Name:ROBERSON FOOT CARE, PA
Entity type:Organization
Organization Name:ROBERSON FOOT CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AINSLEY
Authorized Official - Middle Name:ROBERSON
Authorized Official - Last Name:RUSEVLYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:252-946-1181
Mailing Address - Street 1:114 AVON AVE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-3841
Mailing Address - Country:US
Mailing Address - Phone:252-946-1181
Mailing Address - Fax:252-946-2309
Practice Address - Street 1:114 AVON AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-3841
Practice Address - Country:US
Practice Address - Phone:252-946-1181
Practice Address - Fax:252-946-2309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-02
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC518213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6133110001Medicare NSC