Basic Information
| Provider Information | |||||||||
| NPI: | 1154404952 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | OLIVER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | UNIVERSITY OF MINNESOTA PHYSICIANS | ||||||||
| Address2: | 420 DELAWARE STREET SE | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517723461 | ||||||||
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| Practice Location | |||||||||
| Address1: | UFP PHALEN VILLAGE CLINIC | ||||||||
| Address2: | 1414 MARYLAND AVENUE EAST | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517723461 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 05/11/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 24845 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | 24845 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01-12528 | 01 | MN | MEDICA PRIMARY | OTHER | 102775 | 01 | MN | UCARE | OTHER | 0506013 | 01 | MN | PREFERRED ONE | OTHER | 01-12528 | 01 | MN | MEDICA CHOICE | OTHER | 681282100 | 05 | MN | MEDICAID | 1780296 | 01 | MN | ARAZ | OTHER | 061L6RO | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | HP17043 | 01 | MN | HEALTH PARTNERS | OTHER | 1519736 | 05 | IA | MEDICAID |