Provider Demographics
NPI:1669554465
Name:ROBERTS, ERIC D (ARNP)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:D
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-1329
Mailing Address - Country:US
Mailing Address - Phone:816-217-9916
Mailing Address - Fax:
Practice Address - Street 1:932 LAKE ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1204
Practice Address - Country:US
Practice Address - Phone:331-221-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.013365363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP91321Medicare UPIN