Provider Demographics
NPI:1124287651
Name:WELLIVER, ROBERT CHARLES JR (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CHARLES
Last Name:WELLIVER
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:23 HACKETT BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3436
Practice Address - Country:US
Practice Address - Phone:518-262-3341
Practice Address - Fax:518-262-6660
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2015-01-06
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Provider Licenses
StateLicense IDTaxonomies
IL036-133090208800000X
NY274981208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036133090Medicaid
NY03940636Medicaid
NYJ400156272Medicare PIN
IL256510178Medicare PIN