MEDICARE: DR. JAMES WALLACE ROBERTSON MD

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	208000000X	Pediatrics Physician	4301065685	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457357832
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES WALLACE ROBERTSON MD

Provider Business Mailing Address
First Line	:	5024 N ROYAL DR
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-9230
Country	:	US
Telephone Number	:	231-935-0555
Fax Number	:

Provider Business Practice Location Address
First Line	:	5024 N ROYAL DR
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-9230
Country	:	US
Telephone Number	:	231-935-0555
Fax Number	:	231-935-0562

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

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	12/24/2020

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