Provider Demographics
NPI:1578536207
Name:ROBERSON, VIOLET (DO)
Entity Type:Individual
Prefix:
First Name:VIOLET
Middle Name:
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:M
Other - Last Name:ROBERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3344 W PETERSON AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-3531
Mailing Address - Country:US
Mailing Address - Phone:773-245-3222
Mailing Address - Fax:773-796-5250
Practice Address - Street 1:1215 N ALPINE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-2201
Practice Address - Country:US
Practice Address - Phone:815-391-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036114499207Q00000X, 2083X0100X
WI54043207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIROBERANNOtherMERCYCARE INSURANCE
IL036114499Medicaid
WI541760703Medicare PIN
IL036114499Medicaid
K21772Medicare ID - Type Unspecified