Provider Demographics
NPI:1225091614
Name:ROBERTS, ELLIOTT C JR (MD)
Entity Type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:C
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 1:657 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3903
Mailing Address - Country:US
Mailing Address - Phone:731-541-8425
Mailing Address - Fax:731-541-8420
Practice Address - Street 1:657 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3903
Practice Address - Country:US
Practice Address - Phone:731-541-8425
Practice Address - Fax:731-541-8420
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301048061207VG0400X
TNMD0000043714207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104813136Medicaid
MI104813136Medicaid
D83129Medicare UPIN