Provider Demographics
NPI:1972590420
Name:ROBERTSON, J ALAN (MD)
Entity type:Individual
Prefix:
First Name:J
Middle Name:ALAN
Last Name:ROBERTSON
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 1:17200 E 10 MILE RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-3349
Mailing Address - Country:US
Mailing Address - Phone:586-585-9047
Mailing Address - Fax:586-585-9126
Practice Address - Street 1:17200 E 10 MILE RD
Practice Address - Street 2:SUITE 130
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3349
Practice Address - Country:US
Practice Address - Phone:586-585-9047
Practice Address - Fax:586-585-9126
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301049006207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3441564Medicaid
MI3441564Medicaid
E87912Medicare UPIN