Healthcare Provider Details

I. General information

NPI: 1912974684
Provider Name (Legal Business Name): BRUCE ROBERTS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 POPLAR RD
HIGHLAND PARK IL
60035-4346
US

IV. Provider business mailing address

275 POPLAR RD
HIGHLAND PARK IL
60035-4346
US

V. Phone/Fax

Practice location:
  • Phone: 312-404-4261
  • Fax: 708-202-2085
Mailing address:
  • Phone: 312-404-4261
  • Fax: 708-202-2085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number36057770
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: