Healthcare Provider Details

I. General information

NPI: 1609854421
Provider Name (Legal Business Name): KEVIN W ROBERTS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 01/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 EAST AVE SUITE C
WOODSTOWN NJ
08098-1351
US

IV. Provider business mailing address

125 EAST AVE SUITE C
WOODSTOWN NJ
08098-1351
US

V. Phone/Fax

Practice location:
  • Phone: 856-769-2800
  • Fax: 856-769-4256
Mailing address:
  • Phone: 856-769-2800
  • Fax: 856-769-4256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA05112100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number25MA05112100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: