Provider Demographics
NPI:1093823528
Name:ROBERTS, ROBERT P JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:P
Last Name:ROBERTS
Suffix:JR
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 1:781 KENMOOR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8624
Mailing Address - Country:US
Mailing Address - Phone:616-726-1300
Mailing Address - Fax:616-726-1302
Practice Address - Street 1:781 KENMOOR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8624
Practice Address - Country:US
Practice Address - Phone:616-726-1300
Practice Address - Fax:616-726-1302
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301043739207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1868767Medicaid
MI04100582162Medicare ID - Type Unspecified
B47134Medicare UPIN