Provider Demographics
NPI:1598725285
Name:ROBERTSON, PHILIP BRUNNER (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:BRUNNER
Last Name:ROBERTSON
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 1:347 SANDPIPER AVE
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-4185
Mailing Address - Country:US
Mailing Address - Phone:304-425-2620
Mailing Address - Fax:
Practice Address - Street 1:105 WESTWOOD CMN
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:VA
Practice Address - Zip Code:24605-2031
Practice Address - Country:US
Practice Address - Phone:276-326-2686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-25
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV156042084P0800X
VA01010446222084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0114647000Medicaid
VA7107340Medicaid
WVRO4200491Medicare PIN
VA00X125PO1Medicare PIN
VA7107340Medicaid