Provider Demographics
NPI:1376528802
Name:ROBERTS, J. ROMAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:J. ROMAINE
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JULIA
Other - Middle Name:ROMAINE
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1229 N NORTH BRANCH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-2473
Mailing Address - Country:US
Mailing Address - Phone:312-445-5673
Mailing Address - Fax:312-284-4755
Practice Address - Street 1:1229 N NORTH BRANCH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-2473
Practice Address - Country:US
Practice Address - Phone:312-445-5673
Practice Address - Fax:312-284-4755
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD59996207L00000X
IL036.073364207QG0300X
IN0101233240207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD512302001Medicaid
MDJ784-0001OtherBC/BS
MD512302001Medicaid
MDJ784-0001OtherBC/BS