Healthcare Provider Details

I. General information

NPI: 1205975588
Provider Name (Legal Business Name): MARK S. ROBERTSON, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 06/01/2020
Certification Date: 06/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 29TH AVE SW
ALBANY OR
97321-3415
US

IV. Provider business mailing address

950 29TH AVE SW
ALBANY OR
97321-3415
US

V. Phone/Fax

Practice location:
  • Phone: 541-967-0404
  • Fax: 541-967-7072
Mailing address:
  • Phone: 541-967-0404
  • Fax: 541-967-6548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberDO23994
License Number StateOR

VIII. Authorized Official

Name: DR. MARK STEPHEN ROBERTSON
Title or Position: PHYSICIAN, OWNER
Credential: D.O.
Phone: 541-967-0404