Provider Demographics
NPI:1285797944
Name:ROBERT S. ROBITAILLE DO LLC
Entity type:Organization
Organization Name:ROBERT S. ROBITAILLE DO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:ROBITAILLE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:651-232-2036
Mailing Address - Street 1:PO BOX 1467
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-0467
Mailing Address - Country:US
Mailing Address - Phone:651-232-2036
Mailing Address - Fax:507-387-7368
Practice Address - Street 1:559 CAPITOL BLVD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103-2101
Practice Address - Country:US
Practice Address - Phone:651-232-2036
Practice Address - Fax:507-354-2536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-17
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46841208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN111633900Medicaid
MN23-00504OtherMEDICA
MN631M4ROOtherMN BCBS
MNC05366OtherMEDICARE PTAN