Provider Demographics
NPI:1912974684
Name:ROBERTS, BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
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 1:275 POPLAR RD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-4346
Mailing Address - Country:US
Mailing Address - Phone:312-404-4261
Mailing Address - Fax:708-202-2085
Practice Address - Street 1:275 POPLAR RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-4346
Practice Address - Country:US
Practice Address - Phone:312-404-4261
Practice Address - Fax:708-202-2085
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL360577702084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36057770Medicaid
D14421Medicare UPIN
ILK10851Medicare ID - Type Unspecified
IL36057770Medicaid