MEDICARE: DR. GERALD D ROBERTS 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	31641	MO

General Provider Information

NPI Number	:	1699727818
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GERALD D ROBERTS DO

Provider Business Mailing Address
First Line	:	1101 WEBER RD
Second Line	:	SUITE 101
City	:	FARMINGTON
State	:	MO
Zip	:	63640-3326
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1101 WEBER RD
Second Line	:	SUITE 101
City	:	FARMINGTON
State	:	MO
Zip	:	63640-3326
Country	:	US
Telephone Number	:	573-756-5701
Fax Number	:	573-756-7107

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

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	07/08/2007

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