MEDICARE: SHAWN ROBERTSON

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	207P00000X	Emergency Medicine Physician	036153722	IL
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1962880047
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAWN ROBERTSON

Provider Business Mailing Address
First Line	:	45 N PRINCETON AVE
Second Line	:
City	:	VILLA PARK
State	:	IL
Zip	:	60181-2336
Country	:	US
Telephone Number	:	630-779-9973
Fax Number	:

Provider Business Practice Location Address
First Line	:	45 N PRINCETON AVE
Second Line	:
City	:	VILLA PARK
State	:	IL
Zip	:	60181-2336
Country	:	US
Telephone Number	:	630-779-9973
Fax Number	:

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

Provider Enumeration Date	:	05/11/2015
Last Update Date	:	09/09/2020

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Directions to “ SHAWN ROBERTSON ” Practice Location

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