MEDICARE: DR. KEVIN WALLACE ROBERTSON D.O.

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	5101009588	MI

General Provider Information

NPI Number	:	1780774562
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEVIN WALLACE ROBERTSON D.O.

Provider Business Mailing Address
First Line	:	1375 S LAPEER RD
Second Line	:	SUITE 106
City	:	LAKE ORION
State	:	MI
Zip	:	48360-1421
Country	:	US
Telephone Number	:	248-693-9040
Fax Number	:	248-693-9007

Provider Business Practice Location Address
First Line	:	1375 S LAPEER RD
Second Line	:	SUITE 106
City	:	LAKE ORION
State	:	MI
Zip	:	48360-1421
Country	:	US
Telephone Number	:	248-693-9040
Fax Number	:	248-693-9007

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

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	07/08/2007

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