Provider Demographics
NPI:1689660227
Name:ROBERTS, EDWARD J (PA)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 585
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-0585
Mailing Address - Country:US
Mailing Address - Phone:248-969-3220
Mailing Address - Fax:844-274-3091
Practice Address - Street 1:13137 N CLIO RD
Practice Address - Street 2:
Practice Address - City:CLIO
Practice Address - State:MI
Practice Address - Zip Code:48420-1028
Practice Address - Country:US
Practice Address - Phone:810-686-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002255363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIR80365Medicare UPIN
MIP28070043Medicare PIN