Provider Demographics
NPI:1881653947
Name:ROBERG, JEFF (DO)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:ROBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5435 FELTL RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-7983
Mailing Address - Country:US
Mailing Address - Phone:952-835-9880
Mailing Address - Fax:952-857-1554
Practice Address - Street 1:4050 COON RAPIDS BLVD
Practice Address - Street 2:MERCY HOSPITAL CENTER
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433
Practice Address - Country:US
Practice Address - Phone:763-236-7144
Practice Address - Fax:763-236-7733
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN400615100207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN400615100Medicaid
48027OtherMN MEDICAL LICENSE
MN400615100Medicaid
I32690Medicare UPIN