Healthcare Provider Details

I. General information

NPI: 1154404952
Provider Name (Legal Business Name): WILLIAM OLIVER ROBERTS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 05/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UFP PHALEN VILLAGE CLINIC 1414 MARYLAND AVENUE EAST
SAINT PAUL MN
55106
US

IV. Provider business mailing address

UNIVERSITY OF MINNESOTA PHYSICIANS 420 DELAWARE STREET SE
MINNEAPOLIS MN
55455
US

V. Phone/Fax

Practice location:
  • Phone: 651-772-3461
  • Fax:
Mailing address:
  • Phone: 651-772-3461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24845
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number24845
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: