Provider Demographics
NPI:1073547857
Name:ROBERTS, SCOTT JONATHAN (MPT)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:JONATHAN
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3514 MAYLAND CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-1421
Mailing Address - Country:US
Mailing Address - Phone:804-747-0003
Mailing Address - Fax:804-747-0043
Practice Address - Street 1:3514 MAYLAND CT
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233-1421
Practice Address - Country:US
Practice Address - Phone:804-747-0003
Practice Address - Fax:804-747-0043
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019004823225700000X
VA2305203258174400000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA283517OtherSOUTHERN HEALTH SERVICES
VA192519OtherANTHEM BCBS
VA201597792OtherTRICARE-NORTH
VA2218247OtherFIRST HEALTH
VA201597792OtherBEECH STREET CORPORATION
VA201597792OtherHEALTH NET FEDERAL SERV
VA7230417OtherAETNA
VA0708920OtherUNITED HEALTHCARE
VA150239OtherALLIANCE PPO
VA201597792OtherGREAT-WEST HEALTHCARE
VA2132404OtherM.D.IPA HEALTH PLAN
VA3695288OtherAETNA
VA9028006OtherPHCS
VA9028006OtherPHCS
VAP00295338Medicare ID - Type UnspecifiedPALMETTO GBA