Provider Demographics
NPI:1053364968
Name:MEDBERY, ROBENA ELAINE (MD)
Entity type:Individual
Prefix:
First Name:ROBENA
Middle Name:ELAINE
Last Name:MEDBERY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ROBBIE
Other - Middle Name:ELAINE
Other - Last Name:MEDBERY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:888-472-0043
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:2085 HENRY TECKLENBURG DR STE 106
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-7711
Practice Address - Country:US
Practice Address - Phone:843-958-2440
Practice Address - Fax:843-958-2599
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA509762085R0001X
PAMD057979L2085R0001X
SC258952085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA001381OtherBLUE CROSS/BLUE SHIELD
GA002183OtherBLUE CROSS/BLUESHIELD
GA00941839BMedicaid
GA00941839EMedicaid
GA911235OtherBLUE CROSS/ BLUE SHIELD
GA00941839AMedicaid
SC258955Medicaid
GA00941839CMedicaid
MD114381600Medicaid
MD114381600Medicaid
GA00941839EMedicaid
GA00941839CMedicaid
GA920006876Medicare ID - Type UnspecifiedMEDICARE RAILROAD
GA00941839BMedicaid
GAG50813Medicare UPIN
PA460931Medicare PIN