1700856044 NPI number — DR. JOHN MARK ROBERTS V M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700856044 NPI number — DR. JOHN MARK ROBERTS V M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTS
Provider First Name:
JOHN
Provider Middle Name:
MARK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
V
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700856044
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
237 WILLIAM HOWARD TAFT, PHYS DIV
Provider Second Line Business Mailing Address:
2ND FL, CBO2-3, ATTN: CREDENTIALING
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45219-2906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-792-7445
Provider Business Mailing Address Fax Number:
513-791-4042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9250 BLUE ASH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45242-6822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-792-7445
Provider Business Practice Location Address Fax Number:
513-791-4042
Provider Enumeration Date:
01/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  35.051646 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0591926 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 791945 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: P01191329 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 272352575061 . This is a "CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 272352575 . This is a "MULTIPLAN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 724121 . This is a "WELLCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: H165860 . This is a "MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: P10000903007 . This is a "BUCKEYE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 4026453 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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