1063402394 NPI number — MR. VAN GREGORY ROBERTS PA-C

Table of content: MR. VAN GREGORY ROBERTS PA-C (NPI 1063402394)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063402394 NPI number — MR. VAN GREGORY ROBERTS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTS
Provider First Name:
VAN
Provider Middle Name:
GREGORY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1063402394
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6158 NORTHCLIFF BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUBLIN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43016-6713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-602-7463
Provider Business Mailing Address Fax Number:
614-336-6635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8202 S ACCESS RD BLDG 946
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43217-5903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-989-1213
Provider Business Practice Location Address Fax Number:
614-336-6635
Provider Enumeration Date:
10/27/2005

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: 363AM0700X , with the licence number:  002763 , 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: 002763 . This is a "OHIO LICENSE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com