Basic Information
| Provider Information | |||||||||
| NPI: | 1851332514 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTSON | ||||||||
| FirstName: | THESSA | ||||||||
| MiddleName: | GRACE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 GRANT STREET | ||||||||
| Address2: | |||||||||
| City: | GARY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198864601 | ||||||||
| FaxNumber: | 2198864603 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 GRANT STREET | ||||||||
| Address2: | |||||||||
| City: | GARY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198864601 | ||||||||
| FaxNumber: | 2198864603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 04/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 01061982A | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036113290 | 05 | IL | MEDICAID |