Provider Demographics
NPI:1356377501
Name:DUDLEY ROBERTS M.D, L.L.C.
Entity type:Organization
Organization Name:DUDLEY ROBERTS M.D, L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DUDLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:586-774-8710
Mailing Address - Street 1:18245 E 10 MILE RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-5807
Mailing Address - Country:US
Mailing Address - Phone:586-774-8710
Mailing Address - Fax:586-774-8809
Practice Address - Street 1:18245 E 10 MILE RD
Practice Address - Street 2:SUITE 120
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-5807
Practice Address - Country:US
Practice Address - Phone:586-774-8710
Practice Address - Fax:586-774-8809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDR051585207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4715716Medicaid
MIDR015585OtherLICENSE
MI1105015902OtherBCBS
MIP00240306OtherRAILROAD MEDICARE
MIDR015585OtherLICENSE
MI=========OtherTAX ID
MI4715716Medicaid