Provider Demographics
NPI:1386616449
Name:ROBERTS, LANCE S (DO)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:S
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 PAOLI PIKE
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-3311
Mailing Address - Country:US
Mailing Address - Phone:484-596-5000
Mailing Address - Fax:610-296-4915
Practice Address - Street 1:414 PAOLI PIKE
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:PA
Practice Address - Zip Code:19355-3311
Practice Address - Country:US
Practice Address - Phone:484-596-5000
Practice Address - Fax:610-296-4915
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006197L208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012028150004Medicaid
PAE65413Medicare UPIN
PA608842DOPMedicare ID - Type Unspecified