Provider Demographics
NPI:1356492995
Name:ROBERTS, ROBIN L (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBIN
Middle Name:L
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-2038
Mailing Address - Country:US
Mailing Address - Phone:313-595-9376
Mailing Address - Fax:
Practice Address - Street 1:2178 FORT ST
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-2405
Practice Address - Country:US
Practice Address - Phone:313-388-9693
Practice Address - Fax:313-383-7295
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008741111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7323599OtherCIGNA PROVIDER #
MI95 0 H2 1922 0OtherBCBS PROVIDER #
MI0P03400Medicare ID - Type Unspecified