Provider Demographics
NPI:1396849667
Name:ROBERTSON, SHIRLEY J (MD)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:J
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1540 LAKE LANSING RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-3756
Mailing Address - Country:US
Mailing Address - Phone:517-913-3810
Mailing Address - Fax:517-913-3811
Practice Address - Street 1:1540 LAKE LANSING RD
Practice Address - Street 2:SUITE 102
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-3756
Practice Address - Country:US
Practice Address - Phone:517-913-3810
Practice Address - Fax:517-913-3811
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MISR036051207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4452231OtherAETNA
MI0M21440057OtherMEDICARE ADVANTAGE
MI1021672OtherMCLAREN HEALTH PLAN-MEDICAID
MI200000002859OtherPHP
MI1021672OtherMCLAREN HEALTH ADVANTAGE
MI4926050Medicaid
MI0803307571OtherBLUE CROSS BLUE SHIELD
MI0803307571OtherBLUE CARE NETWORK
MI1021672OtherMCLAREN HEALTH PLAN-COMMERCIAL
MI200000002622OtherPHP FAMILYCARE
MI4397827Medicaid
MI1021672OtherMCLAREN HEALTH PLAN-COMMERCIAL
MI200000002859OtherPHP