Basic Information
| Provider Information | |||||||||
| NPI: | 1750322970 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 634706 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452630001 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4370 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363051056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159286268 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 10/01/2019 | ||||||||
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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 | 207P00000X | 38264 | KY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3809726 | 05 | TN | MEDICAID | 000835238E | 05 | GA | MEDICAID | P00101677 | 01 | TN | MEDICARE RAILROAD | OTHER | 009941819 | 05 | AL | MEDICAID | 3072473 | 01 | TN | BLUE CROSS | OTHER | 3094174 | 01 | TN | BLUE CROSS | OTHER | 3809727 | 05 | TN | MEDICAID | 05873366 | 05 | MS | MEDICAID | 232902 | 05 | SC | MEDICAID | 3809728 | 05 | TN | MEDICAID | FR6862773 | 01 | AL | DEA | OTHER | 50003547 | 01 | KY | PASSPORT HEALTH | OTHER | 64004096 | 05 | KY | MEDICAID | P00233191 | 01 | TN | MEDICARE RAILROAD | OTHER | P00292503 | 01 | TN | MEDICARE RAILROAD | OTHER |