Provider Demographics
NPI:1740273671
Name:ROBERTS, THOMAS HENRY (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:HENRY
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-3301
Mailing Address - Country:US
Mailing Address - Phone:219-873-3130
Mailing Address - Fax:219-873-3132
Practice Address - Street 1:ST ANTHONY MEMORIAL HOSPITAL
Practice Address - Street 2:301 E HOMER ST
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360
Practice Address - Country:US
Practice Address - Phone:219-861-8688
Practice Address - Fax:219-877-1081
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026864A207ZC0500X, 207ZP0102X
IL207ZC0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
6290876002OtherCIGNA
IL01630255OtherBC/BC
IN1003877130AMedicaid
IN82439OtherBC/BS
6290876002OtherCIGNA
E13648Medicare UPIN
IN652630HMedicare PIN