Provider Demographics
NPI:1346224342
Name:ROBERTS, ELLEN GOFF (MD)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:GOFF
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 STERLING WAY
Mailing Address - Street 2:STE 1
Mailing Address - City:MT STERLING
Mailing Address - State:KY
Mailing Address - Zip Code:40353
Mailing Address - Country:US
Mailing Address - Phone:859-498-0200
Mailing Address - Fax:859-498-5812
Practice Address - Street 1:100 STERLING WAY
Practice Address - Street 2:STE 1
Practice Address - City:MT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353
Practice Address - Country:US
Practice Address - Phone:859-498-0200
Practice Address - Fax:859-498-5812
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY208032085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64208036Medicaid
KY000000353871OtherANTHEM
KY000000353871OtherANTHEM
KY0714506Medicare ID - Type Unspecified