Provider Demographics
NPI:1316150113
Name:ROBERTS DERMATOLOGY CENTER, P.C.
Entity type:Organization
Organization Name:ROBERTS DERMATOLOGY CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:810-245-7766
Mailing Address - Street 1:3273 DAVISON RD STE 5
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-4306
Mailing Address - Country:US
Mailing Address - Phone:810-245-7766
Mailing Address - Fax:810-245-6216
Practice Address - Street 1:3273 DAVISON RD STE 5
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-4306
Practice Address - Country:US
Practice Address - Phone:810-245-7766
Practice Address - Fax:810-245-6216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010293207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4115633Medicaid
MI4115633Medicaid
MI0M82590Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER