Provider Demographics
NPI:1437145695
Name:ROBERTS, ANN ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:ELIZABETH
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:1230 MARKET ST
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-7986
Practice Address - Country:US
Practice Address - Phone:502-225-6900
Practice Address - Fax:502-666-7693
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY26442208D00000X
KYKY26442207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3722091000OtherPASSPORT ADVANTAGE
KY000000617689OtherANTHEM
KY64264427Medicaid
KY50024361OtherPASSPORT
KYP00746838OtherRAILROAD MEDICARE
KY50024361OtherPASSPORT
KYP00746838OtherRAILROAD MEDICARE
KY000000617689OtherANTHEM