MEDICARE: MR. ROBERT OSCAR ROBERTSON DO

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	207Q00000X	Family Medicine Physician	5101007194	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P62172	OTHER		AETNA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	700C86358	OTHER	MI	BCBS

General Provider Information

NPI Number	:	1336137892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT OSCAR ROBERTSON DO

Provider Business Mailing Address
First Line	:	300 W WASHINGTON AVE
Second Line	:	STE 150
City	:	JACKSON
State	:	MI
Zip	:	49201-2180
Country	:	US
Telephone Number	:	517-783-4664
Fax Number	:	517-783-4698

Provider Business Practice Location Address
First Line	:	300 W WASHINGTON AVE
Second Line	:	STE 150
City	:	JACKSON
State	:	MI
Zip	:	49201-2180
Country	:	US
Telephone Number	:	517-783-4664
Fax Number	:	517-783-4698

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

Provider Enumeration Date	:	10/10/2005
Last Update Date	:	10/04/2011

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Directions to “ MR. ROBERT OSCAR ROBERTSON DO” Practice Location

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