Basic Information
| Provider Information | |||||||||
| NPI: | 1770524951 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CONCEPCION | ||||||||
| FirstName: | ROBERTO | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | L-3549 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432600001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403837927 | ||||||||
| FaxNumber: | 7403837942 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 DELAWARE AVENUE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433011814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403837950 | ||||||||
| FaxNumber: | 7403758164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 10/07/2014 | ||||||||
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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 | 208800000X | 35049715C | OH | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 35.049715 | OH | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 340006973 | 01 | TRAVELERS MEDICARE | OTHER | 1900051 | 01 | UHC | OTHER | 311098079 | 01 | TAX ID # | OTHER | 0647181 | 01 | PALMETTO MEDICARE | OTHER | 353077 | 01 | SUBMITTER NO. | OTHER | 643269 | 01 | AETNA | OTHER | 0567686 | 05 | OH | MEDICAID | 311098079007 | 01 | CIGNA | OTHER |