Provider Demographics
NPI:1871789347
Name:DR GORDON L ROBERTS PLLC
Entity type:Organization
Organization Name:DR GORDON L ROBERTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:269-751-2670
Mailing Address - Street 1:3426 M-40
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MI
Mailing Address - Zip Code:49419
Mailing Address - Country:US
Mailing Address - Phone:269-751-2670
Mailing Address - Fax:269-751-2680
Practice Address - Street 1:3426 M-40
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MI
Practice Address - Zip Code:49419
Practice Address - Country:US
Practice Address - Phone:269-751-2670
Practice Address - Fax:269-751-2680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIGR004365111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI9502310340OtherBLUE CROSS BLUE SHIELD
MI4718950Medicaid
MI650240OtherUNITED HEALTH CARE
MI650240OtherUNITED HEALTH CARE