Provider Demographics
NPI:1588663553
Name:ROBECK, ILENE RAE (MD)
Entity Type:Individual
Prefix:DR
First Name:ILENE
Middle Name:RAE
Last Name:ROBECK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:6381 18TH ST NE
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-4703
Mailing Address - Country:US
Mailing Address - Phone:571-259-2057
Mailing Address - Fax:727-289-1398
Practice Address - Street 1:6381 18TH ST NE
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-4703
Practice Address - Country:US
Practice Address - Phone:727-289-1396
Practice Address - Fax:727-289-1398
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101033181207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA54-1314405OtherTAXID
B94361Medicare UPIN