Provider Demographics
NPI:1194752287
Name:BLIESATH, ROBERT DOUGLAS (PA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:DOUGLAS
Last Name:BLIESATH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 EXECUTIVE CIR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-3345
Mailing Address - Country:US
Mailing Address - Phone:912-355-2400
Mailing Address - Fax:912-355-5324
Practice Address - Street 1:5 EXECUTIVE CIR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3345
Practice Address - Country:US
Practice Address - Phone:912-355-2400
Practice Address - Fax:912-355-5324
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003117363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100001614BMedicaid
GA100001614AMedicaid
GA10059029OtherAMERIGROUP
S81782Medicare UPIN
GA10059029OtherAMERIGROUP
GA930072580Medicare PIN