Healthcare Provider Details

I. General information

NPI: 1407010879
Provider Name (Legal Business Name): ERIC G ROBERTS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2008
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 W OKLAHOMA AVE 4TH FLOOR GALLERIA
MILWAUKEE WI
53215
US

IV. Provider business mailing address

2900 W OKLAHOMA AVE 4TH FL
MILWAUKEE WI
53215-4330
US

V. Phone/Fax

Practice location:
  • Phone: 414-646-5410
  • Fax:
Mailing address:
  • Phone: 414-646-2438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125053403
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number55936
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: