Provider Demographics
NPI:1326263252
Name:JOHN E ROBERTS III MD PLLC
Entity Type:Organization
Organization Name:JOHN E ROBERTS III MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:TREMBLAY
Authorized Official - Suffix:
Authorized Official - Credentials:MED ASST
Authorized Official - Phone:954-491-6400
Mailing Address - Street 1:5700 N FEDERAL HWY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-2600
Mailing Address - Country:US
Mailing Address - Phone:954-491-6400
Mailing Address - Fax:954-771-8835
Practice Address - Street 1:5700 N FEDERAL HWY
Practice Address - Street 2:SUITE 1
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-2600
Practice Address - Country:US
Practice Address - Phone:954-491-6400
Practice Address - Fax:954-771-8835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00563OtherBLUE CROSS BLUE SHIELD
FLAG131Medicare PIN