Provider Demographics
NPI:1710964143
Name:WARREN, ROBERT C (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:C
Last Name:WARREN
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 1:125 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-6400
Mailing Address - Country:US
Mailing Address - Phone:440-328-3450
Mailing Address - Fax:216-201-6330
Practice Address - Street 1:125 E BROAD ST STE 101
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-6429
Practice Address - Country:US
Practice Address - Phone:440-328-3450
Practice Address - Fax:216-201-6330
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35068419W208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0150429Medicaid
OH0236248Medicaid
OH3025372Medicaid
OH3025372Medicaid
OH0236248Medicaid
OH9284951Medicare PIN
OH4038341Medicare ID - Type Unspecified
OH0150429Medicaid