Provider Demographics
NPI:1235217456
Name:ROBERTS, MELVILLE PARKER
Entity Type:Individual
Prefix:
First Name:MELVILLE
Middle Name:PARKER
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 ANDOVER RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-1954
Mailing Address - Country:US
Mailing Address - Phone:207-761-6642
Mailing Address - Fax:207-773-2603
Practice Address - Street 1:10 ANDOVER RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-1954
Practice Address - Country:US
Practice Address - Phone:207-761-6642
Practice Address - Fax:207-773-2603
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME015187208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME287310099Medicaid
ME154600000Medicaid
ME043376482OtherFEDERAL TAX ID
ME043376482OtherFEDERAL TAX ID
ME154600000Medicaid
MEE94964Medicare UPIN