Provider Demographics
NPI:1104849868
Name:URBAN, ROBERT J (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:URBAN
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 1:500 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANISTIQUE
Mailing Address - State:MI
Mailing Address - Zip Code:49854-1522
Mailing Address - Country:US
Mailing Address - Phone:906-341-2153
Mailing Address - Fax:906-341-3299
Practice Address - Street 1:500 MAIN ST
Practice Address - Street 2:
Practice Address - City:MANISTIQUE
Practice Address - State:MI
Practice Address - Zip Code:49854-1522
Practice Address - Country:US
Practice Address - Phone:906-341-2153
Practice Address - Fax:906-341-3299
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301033860261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4767660Medicaid
MIB44925Medicare UPIN
MI4767660Medicaid