Provider Demographics
NPI:1992799894
Name:MCROBERTS, ANDREW W (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:W
Last Name:MCROBERTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DREW
Other - Middle Name:WILLIAM
Other - Last Name:MCROBERTS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:500 S 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4881
Mailing Address - Country:US
Mailing Address - Phone:208-232-7434
Mailing Address - Fax:208-233-6446
Practice Address - Street 1:777 HOSPITAL WAY
Practice Address - Street 2:BUILDING A SUITE 201
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5175
Practice Address - Country:US
Practice Address - Phone:208-239-2620
Practice Address - Fax:208-239-3778
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6814208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002768500Medicaid
ID002768500Medicaid
ID1132701Medicare ID - Type Unspecified