Healthcare Provider Details

I. General information

NPI: 1962473637
Provider Name (Legal Business Name): ROGER ANDERBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 E EISENHOWER PKWY SUITE 100
ANN ARBOR MI
48108-5205
US

IV. Provider business mailing address

2100 COMMONWEALTH BLVD SUITE 202
ANN ARBOR MI
48105-1593
US

V. Phone/Fax

Practice location:
  • Phone: 734-971-9344
  • Fax:
Mailing address:
  • Phone: 734-747-6766
  • Fax: 734-747-8605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301049376
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: