Provider Demographics
NPI:1225089626
Name:ROBERTS, NATHAN L (MD)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:L
Last Name:ROBERTS
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 1:101 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3909
Mailing Address - Country:US
Mailing Address - Phone:217-253-9258
Mailing Address - Fax:217-253-9318
Practice Address - Street 1:300 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TUSCOLA
Practice Address - State:IL
Practice Address - Zip Code:61953-1406
Practice Address - Country:US
Practice Address - Phone:217-253-9258
Practice Address - Fax:217-253-9318
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036104517207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036104517Medicaid
IL036104517Medicaid
ILIL3270289Medicare PIN
ILK06175Medicare PIN
H46976Medicare UPIN
ILH46976Medicare UPIN