Provider Demographics
NPI:1679036891
Name:ILLUMINATE MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:ILLUMINATE MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:B
Authorized Official - Last Name:ROBERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:940-220-9996
Mailing Address - Street 1:1028 TRUMAN RD
Mailing Address - Street 2:
Mailing Address - City:LANTANA
Mailing Address - State:TX
Mailing Address - Zip Code:76226-4395
Mailing Address - Country:US
Mailing Address - Phone:940-220-9996
Mailing Address - Fax:
Practice Address - Street 1:1028 TRUMAN RD
Practice Address - Street 2:
Practice Address - City:LANTANA
Practice Address - State:TX
Practice Address - Zip Code:76226-4395
Practice Address - Country:US
Practice Address - Phone:940-220-9996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-14
Last Update Date:2019-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty