Healthcare Provider Details

I. General information

NPI: 1851383814
Provider Name (Legal Business Name): TANYA ROBERTS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 09/22/2023
Certification Date: 09/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 MAIN ST STE 102
DYER IN
46311-3717
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 219-934-2492
  • Fax: 219-934-8493
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01059615A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: