Healthcare Provider Details

I. General information

NPI: 1710202122
Provider Name (Legal Business Name): BRIAN WILLIAM ROBERTS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2010
Last Update Date: 11/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 COOPER PLZ
CAMDEN NJ
08103-1461
US

IV. Provider business mailing address

1 COOPER PLZ
CAMDEN NJ
08103-1461
US

V. Phone/Fax

Practice location:
  • Phone: 856-342-2351
  • Fax:
Mailing address:
  • Phone: 856-342-2351
  • Fax: 856-968-8572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number25MA08889000
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMT196382
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: