Basic Information
| Provider Information | |||||||||
| NPI: | 1407848849 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOODBURN | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8702 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464107035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197385598 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8702 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464107035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197385598 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 01052621A | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 307891112 | 05 | IL | MEDICAID | P00368101 | 01 | IL | RAIL ROAD MEDICARE | OTHER | 000000251225 | 01 | IN | ANTHEM | OTHER | P00051343 | 01 | IN | RAIL ROAD MEDICARE | OTHER | 200310530 | 05 | IN | MEDICAID |