Basic Information
Provider Information | |||||||||
NPI: | 1982635348 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROBERMAN | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | GILCREASE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2900 E 29TH ST STE 100 | ||||||||
Address2: |   | ||||||||
City: | BRYAN | ||||||||
State: | TX | ||||||||
PostalCode: | 778022623 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9797768440 | ||||||||
FaxNumber: | 8776015854 | ||||||||
Practice Location | |||||||||
Address1: | 2900 E 29TH ST STE 200 | ||||||||
Address2: |   | ||||||||
City: | BRYAN | ||||||||
State: | TX | ||||||||
PostalCode: | 778022623 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9797768440 | ||||||||
FaxNumber: | 8776015854 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/05/2006 | ||||||||
LastUpdateDate: | 07/15/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/15/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | H9951 | TX | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 8BR219 | 01 | TX | BCBS | OTHER | 122145907 | 05 | TX |   | MEDICAID | P082124N3 | 05 | TX |   | MEDICAID |