Basic Information
| Provider Information | |||||||||
| NPI: | 1417924879 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RASTER | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 403 E MADISON ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466172322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742340061 | ||||||||
| FaxNumber: | 5742831209 | ||||||||
| Practice Location | |||||||||
| Address1: | 403 E MADISON ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466172322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742340061 | ||||||||
| FaxNumber: | 5742831209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2006 | ||||||||
| LastUpdateDate: | 11/02/2009 | ||||||||
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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 | 2084P0800X | 01045140 | IN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 200103420A | 05 | IN | MEDICAID |