MEDICARE: MR. VAN GREGORY ROBERTS PA-C

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	363AM0700X	Medical Physician Assistant	002763	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	002763	OTHER	OH	OHIO LICENSE

General Provider Information

NPI Number	:	1063402394
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. VAN GREGORY ROBERTS PA-C

Provider Business Mailing Address
First Line	:	6158 NORTHCLIFF BLVD
Second Line	:
City	:	DUBLIN
State	:	OH
Zip	:	43016-6713
Country	:	US
Telephone Number	:	301-602-7463
Fax Number	:	614-336-6635

Provider Business Practice Location Address
First Line	:	8202 S ACCESS RD BLDG 946
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43217-5903
Country	:	US
Telephone Number	:	614-989-1213
Fax Number	:	614-336-6635

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

Provider Enumeration Date	:	10/27/2005
Last Update Date	:	12/15/2021

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