=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396735429
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | R MICHAEL ROBERTS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2005
-----------------------------------------------------
Last Update Date | 09/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 EWING ST A-8
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08540-2757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-921-6555
-----------------------------------------------------
Fax | 609-924-5911
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 EWING ST A-8
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08540-2757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-921-6555
-----------------------------------------------------
Fax | 609-924-5911
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | 25MA02945000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------