Provider Demographics
NPI:1497797484
Name:MEREDITH, ROBERT L (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:MEREDITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 S VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3526
Mailing Address - Country:US
Mailing Address - Phone:920-433-8180
Mailing Address - Fax:920-431-3245
Practice Address - Street 1:835 S VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3526
Practice Address - Country:US
Practice Address - Phone:920-433-8180
Practice Address - Fax:920-431-3245
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI34542207UN0902X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104455742OtherMICHIGAN MED ASSISTANCE
WI32422700Medicaid
WI360004256OtherRAILROAD MEDICARE
MI104455742OtherMICHIGAN MED ASSISTANCE
WI32422700Medicaid