Provider Demographics
NPI:1205975588
Name:MARK S. ROBERTSON, P.C.
Entity type:Organization
Organization Name:MARK S. ROBERTSON, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:541-967-0404
Mailing Address - Street 1:950 29TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-3415
Mailing Address - Country:US
Mailing Address - Phone:541-967-0404
Mailing Address - Fax:541-967-6548
Practice Address - Street 1:950 29TH AVE SW
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-3415
Practice Address - Country:US
Practice Address - Phone:541-967-0404
Practice Address - Fax:541-967-7072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO23994207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286847Medicaid
OR286847Medicaid
ORG83850Medicare UPIN