=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609917418
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY A ROBERTSON M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2007
-----------------------------------------------------
Last Update Date | 12/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 S DOBSON RD STE 204
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85286-6160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-726-3606
-----------------------------------------------------
Fax | 623-208-5075
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 33269
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85067-3269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-406-4786
-----------------------------------------------------
Fax | 916-636-4358
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 17506
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
=====================================================
Legacy Identifiers
=====================================================
Identifier #1
-----------------------------------------------------
Identifier Code | 296170-004
-----------------------------------------------------
Identifier Type | MEDICAID
-----------------------------------------------------
Identifier State | AZ
-----------------------------------------------------
Identifier Issuer |
-----------------------------------------------------
=====================================================
Proprietary Identifiers Ever Reported
=====================================================
Identifier #1
-----------------------------------------------------
Identifier Code | 296170-004
-----------------------------------------------------
Identifier Type | MEDICAID
-----------------------------------------------------
Identifier State | AZ
-----------------------------------------------------
Identifier Issuer |
-----------------------------------------------------