Provider Demographics
NPI:1851332514
Name:ROBERTSON, THESSA GRACE (MD)
Entity Type:Individual
Prefix:
First Name:THESSA
Middle Name:GRACE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 GRANT STREET
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46402
Mailing Address - Country:US
Mailing Address - Phone:219-886-4601
Mailing Address - Fax:219-886-4603
Practice Address - Street 1:600 GRANT STREET
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46402
Practice Address - Country:US
Practice Address - Phone:219-886-4601
Practice Address - Fax:219-886-4603
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061982A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036113290Medicaid
P00225194Medicare ID - Type UnspecifiedRAILROAD MEDICARE
K18192Medicare ID - Type Unspecified