Provider Demographics
NPI:1275565442
Name:ROBERTS, MARK A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
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 1:106 EDWINA STREET
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:AL
Mailing Address - Zip Code:36401
Mailing Address - Country:US
Mailing Address - Phone:251-578-4300
Mailing Address - Fax:251-578-4307
Practice Address - Street 1:106 EDWINA STREET
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:AL
Practice Address - Zip Code:36401
Practice Address - Country:US
Practice Address - Phone:251-578-4300
Practice Address - Fax:251-578-4307
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15010207QH0002X, 207Q00000X
ALPM.282208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051558849Medicaid
AL83583Medicare ID - Type Unspecified