MEDICARE: DR. ILENE RAE ROBECK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	0101033181	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	54-1314405	OTHER	VA	TAXID

General Provider Information

NPI Number	:	1588663553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ILENE RAE ROBECK MD

Provider Business Mailing Address
First Line	:	6381 18TH ST NE
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33702-4703
Country	:	US
Telephone Number	:	571-259-2057
Fax Number	:	727-289-1398

Provider Business Practice Location Address
First Line	:	6381 18TH ST NE
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33702-4703
Country	:	US
Telephone Number	:	727-289-1396
Fax Number	:	727-289-1398

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2005
Last Update Date	:	03/26/2014

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