Provider Demographics
NPI:1093717027
Name:ROBERTSON, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ROBERTSON
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 1:612 ROXBURY RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5089
Mailing Address - Country:US
Mailing Address - Phone:815-227-8300
Mailing Address - Fax:815-227-8301
Practice Address - Street 1:612 ROXBURY RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5089
Practice Address - Country:US
Practice Address - Phone:815-227-8300
Practice Address - Fax:815-227-8301
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036108880207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35332700Medicaid
IL1616108OtherBCBS
IL$$$$$$$$$Medicaid
ILK51148Medicare PIN
WI35332700Medicaid
IL211215Medicare PIN
IL1616108OtherBCBS
ILI26013Medicare UPIN
ILCK5424Medicare PIN