Provider Demographics
NPI:1497799878
Name:ROBERTS, KEVIN G (DC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:G
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:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:63645-0189
Mailing Address - Country:US
Mailing Address - Phone:573-783-3188
Mailing Address - Fax:573-783-3314
Practice Address - Street 1:713 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:MO
Practice Address - Zip Code:63645-1113
Practice Address - Country:US
Practice Address - Phone:573-783-3188
Practice Address - Fax:573-783-3314
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004431111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO106834OtherHEALTHLINK ID #
MO12362OtherBLUE CROSS ID #
MO0497085OtherHEALTHLINK ID #
MO4407100OtherUNITED HEALTHCARE ID #
MO0497085OtherCIGNA ID #
MO000013947OtherMEDICARE GROUP
MO752824805Medicaid
MO0497085OtherHEALTHLINK ID #
MO106834OtherHEALTHLINK ID #