MEDICARE: DR. LISA MARIE ROBERTS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VG0400X	Gynecology Physician	9701567	NC

General Provider Information

NPI Number	:	1053372888
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA MARIE ROBERTS M.D.

Provider Business Mailing Address
First Line	:	10941 RAVEN RIDGE RD
Second Line	:	SUITE 109
City	:	RALEIGH
State	:	NC
Zip	:	27614-6487
Country	:	US
Telephone Number	:	919-847-7475
Fax Number	:	919-847-7471

Provider Business Practice Location Address
First Line	:	10941 RAVEN RIDGE RD
Second Line	:	SUITE 109
City	:	RALEIGH
State	:	NC
Zip	:	27614-6487
Country	:	US
Telephone Number	:	919-847-7475
Fax Number	:	919-847-7471

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2006
Last Update Date	:	07/07/2010

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