Provider Demographics
NPI:1639153224
Name:ROBERTS, ALISA (DO)
Entity Type:Individual
Prefix:DR
First Name:ALISA
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 SMITH STEWART RD
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44473-9619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1250 S WASHINGTON ST
Practice Address - Street 2:PHOENIX EMERGENCY PHYSICIANS OF THE MIDWEST
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891-2551
Practice Address - Country:US
Practice Address - Phone:419-238-8611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34008346207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2621265Medicaid
OH000000522415OtherANTHEM
OH000000537055OtherANTHEM
OH000000522415OtherANTHEM
OHRO7339331Medicare PIN
OHRO4189343Medicare PIN