Basic Information
| Provider Information | |||||||||
| NPI: | 1851419378 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | EARL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1671 CROOKED OAK DR | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176014269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175695331 | ||||||||
| FaxNumber: | 7175694210 | ||||||||
| Practice Location | |||||||||
| Address1: | 1671 CROOKED OAK DR | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176014269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175695331 | ||||||||
| FaxNumber: | 7175694210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 05/05/2014 | ||||||||
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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 | 208100000X | MD430606 | PA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 102156863-0002 | 05 | PA | MEDICAID |