Healthcare Provider Details

I. General information

NPI: 1629890272
Provider Name (Legal Business Name): MICHAEL ROBERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2024
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3974 SPRINGFIELD RD
GLEN ALLEN VA
23060-4119
US

IV. Provider business mailing address

3974 SPRINGFIELD RD
GLEN ALLEN VA
23060-4119
US

V. Phone/Fax

Practice location:
  • Phone: 804-495-8661
  • Fax: 804-486-9819
Mailing address:
  • Phone: 804-495-8661
  • Fax: 804-486-9819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number0735001041
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: