Provider Demographics
NPI:1750561064
Name:MICHELE ROBERTS, LLC
Entity type:Organization
Organization Name:MICHELE ROBERTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GNP
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:GNP
Authorized Official - Phone:636-244-4500
Mailing Address - Street 1:6209 MID RIVERS MALL DR
Mailing Address - Street 2:#317
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63304-1102
Mailing Address - Country:US
Mailing Address - Phone:636-244-4500
Mailing Address - Fax:636-244-4505
Practice Address - Street 1:6209 MID RIVERS MALL DR
Practice Address - Street 2:#317
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63304-1102
Practice Address - Country:US
Practice Address - Phone:636-244-4500
Practice Address - Fax:636-244-4505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103362363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MODB9981OtherRAILROAD MEDICARE
MODB9981OtherRAILROAD MEDICARE