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General NPI Number Information
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NPI Number | 1730677881
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Entity Type | Individual
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Provider Name | MARK A ROBERTS MD, PHD
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Gender | Male
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Dates
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Enumeration Date | 04/24/2018
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Last Update Date | 04/24/2018
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Provider Practice Location Address
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Address Line | 10552 N WATTS SPRINGS PARK RD
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City | EDGERTON
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State | WI
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Zip | 53534-8947
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Country | US
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Telephone | 312-961-9391
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 111
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City | EDGERTON
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State | WI
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Zip | 53534-0111
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Country | US
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Telephone | 312-961-9391
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2083X0100X
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Taxonomy Name | Occupational Medicine Physician
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License Number | 16402
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 2083X0100X
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Taxonomy Name | Occupational Medicine Physician
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License Number | 31165
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License Number State | WI
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