Provider Demographics
NPI:1316922354
Name:EISENBERG, ROBERT A (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:EISENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-7694
Mailing Address - Country:US
Mailing Address - Phone:678-312-4440
Mailing Address - Fax:
Practice Address - Street 1:1000 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7694
Practice Address - Country:US
Practice Address - Phone:678-312-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA271832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300052033OtherRR MEDICARE
GA000443451Medicaid
GAP00990743OtherRR MEDICARE
E91400Medicare UPIN
GAP00990743OtherRR MEDICARE
GA511I300053Medicare PIN
GA511G700002Medicare PIN
GA47BBBPKMedicare ID - Type UnspecifiedGA IDTF