Basic Information
| Provider Information | |||||||||
| NPI: | 1407010879 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 W OKLAHOMA AVE | ||||||||
| Address2: | 4TH FL | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532154330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146462438 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2900 W OKLAHOMA AVE | ||||||||
| Address2: | 4TH FLOOR GALLERIA | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146465410 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2008 | ||||||||
| LastUpdateDate: | 12/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 125053403 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 55936 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | CE9230 | 01 | RAILROAD MEDICARE PTAN (GROUP) | OTHER | P00880127 | 01 | RAILROAD MEDICARE PTAN (INDIVIDUAL) | OTHER | 036125276 | 05 | IL | MEDICAID | 206147 | 01 | MEDICARE PTAN (GROUP) | OTHER | 206147021 | 01 | MEDICARE PTAN (INDIVIDUAL) | OTHER | 100031179 | 05 | WI | MEDICAID |