Provider Demographics
NPI:1811061559
Name:ROBERTS, MICHAEL CARL (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CARL
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12745 LEXINGTON ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON
Mailing Address - State:TN
Mailing Address - Zip Code:38344-3720
Mailing Address - Country:US
Mailing Address - Phone:731-986-2120
Mailing Address - Fax:731-986-3373
Practice Address - Street 1:12745 LEXINGTON ST
Practice Address - Street 2:
Practice Address - City:HUNTINGDON
Practice Address - State:TN
Practice Address - Zip Code:38344-3720
Practice Address - Country:US
Practice Address - Phone:731-986-2120
Practice Address - Fax:731-986-3373
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC0000001372111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN350042566OtherRAILROAD MEDICARE
TN62-1685843OtherTAX ID #
TN44-40326OtherUNITED HEALTHCARE
TN3813461Medicaid
TNWT2052OtherCIGNA
TN5729484OtherAETNA
TN3062025OtherBLUE CROSS BLUE SHIELD
TN3813461Medicaid
TN44-40326OtherUNITED HEALTHCARE