Healthcare Provider Details

I. General information

NPI: 1699709592
Provider Name (Legal Business Name): GREGORY L ROBERTS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 04/29/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 GRANT UTELY AVE NW
CASS LAKE MN
56633
US

IV. Provider business mailing address

219 GRANT UTELY AVE NW PO BOX 67
CASS LAKE MN
56633
US

V. Phone/Fax

Practice location:
  • Phone: 218-335-2559
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30341
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36046
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: