Provider Demographics
NPI:1184655409
Name:ROBERTSON, MICHAEL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
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 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8075 N SHADELAND AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2693
Practice Address - Country:US
Practice Address - Phone:317-621-8500
Practice Address - Fax:317-621-8501
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062394A207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200846350AMedicaid
INP01214702OtherRR MEDICARE PTAN
IN2686300OtherAETNA
IN251320KMedicare PIN
IN248520YYMedicare PIN
INP01214702OtherRR MEDICARE PTAN
INP00355761Medicare PIN
IN266180171Medicare PIN
INI01830Medicare UPIN
IN230360DMedicare PIN