Provider Demographics
NPI:1265638902
Name:JOHN W ROBERTSON III MD, PC
Entity Type:Organization
Organization Name:JOHN W ROBERTSON III MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-763-1024
Mailing Address - Street 1:8080 OLD YORK RD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-1421
Mailing Address - Country:US
Mailing Address - Phone:267-763-1024
Mailing Address - Fax:267-763-1050
Practice Address - Street 1:8080 OLD YORK RD
Practice Address - Street 2:SUITE 212
Practice Address - City:ELKINS PARK
Practice Address - State:PA
Practice Address - Zip Code:19027-1421
Practice Address - Country:US
Practice Address - Phone:267-763-1024
Practice Address - Fax:267-763-1050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044947E2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0013045930007Medicaid
PAF19982Medicare UPIN
PA0013045930007Medicaid