Basic Information
| Provider Information | |||||||||
| NPI: | 1366434342 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBERTSON | ||||||||
| FirstName: | ROY | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11109 PARKVIEW PLAZA DR # 117 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451701 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11108 PARKVIEW CIRCLE DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602665700 | ||||||||
| FaxNumber: | 2602669520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 10/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 01037760A | IN | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 207R00000X | 01037760A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0011X | 01037760A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 208600000X | 01037760A | IN | N | Allopathic & Osteopathic Physicians | Surgery | 207RC0000X | 01037760A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 000000641097 | 01 | IN | ANTHEM | OTHER | 060070573 | 01 | IN | RR MEDICARE | OTHER | 0977117 | 05 | OH | MEDICAID | P00782372 | 01 | IN | R.R. MEDICARE | OTHER | 100465520 | 05 | IN | MEDICAID |