Healthcare Provider Details

I. General information

NPI: 1053314781
Provider Name (Legal Business Name): THOM R ROBERTS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2005
Last Update Date: 03/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 CORAOPOLIS HEIGHTS RD STE E
MOON TWP PA
15108-4316
US

IV. Provider business mailing address

11279 PERRY HWY STE 450
WEXFORD PA
15090-9303
US

V. Phone/Fax

Practice location:
  • Phone: 412-262-2415
  • Fax: 412-262-1537
Mailing address:
  • Phone: 724-933-1100
  • Fax: 724-933-1160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD014639E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0007224360003
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: