Healthcare Provider Details

I. General information

NPI: 1225089626
Provider Name (Legal Business Name): NATHAN L ROBERTS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N MAIN ST
TUSCOLA IL
61953-1406
US

IV. Provider business mailing address

101 W UNIVERSITY AVE
CHAMPAIGN IL
61820-3909
US

V. Phone/Fax

Practice location:
  • Phone: 217-253-9258
  • Fax: 217-253-9318
Mailing address:
  • Phone: 217-253-9258
  • Fax: 217-253-9318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036104517
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: