Provider Demographics
NPI:1316946072
Name:ROBERG, BRADFORD C (MD)
Entity type:Individual
Prefix:
First Name:BRADFORD
Middle Name:C
Last Name:ROBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8135 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-2828
Mailing Address - Country:US
Mailing Address - Phone:847-967-8098
Mailing Address - Fax:847-967-8594
Practice Address - Street 1:5714 S STATE ROUTE 31
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-4520
Practice Address - Country:US
Practice Address - Phone:815-356-7000
Practice Address - Fax:815-356-7513
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2007-07-08
Deactivation Date:2006-03-18
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
IL2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL00732007OtherBLUE SHIELD OF ILLINOIS
ILC75640Medicare UPIN
IL319960Medicare ID - Type Unspecified