Basic Information
| Provider Information | |||||||||
| NPI: | 1184997918 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERSON | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | ALEXANDER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3298 | ||||||||
| Address2: | |||||||||
| City: | CAROL STREAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601320001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614788770 | ||||||||
| FaxNumber: | 5615987231 | ||||||||
| Practice Location | |||||||||
| Address1: | 947 TYRONE BLVD N | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337106332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273433019 | ||||||||
| FaxNumber: | 7273430606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2012 | ||||||||
| LastUpdateDate: | 04/04/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | AZ633 | FL | N | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 231H00000X | AY1779 | FL | Y | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.