Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0122X | Plastic and Reconstructive Surgery | IL |
NPI | 1316946072 |
---|---|
Provider Name | Bradford C Roberg |
First Address | Niles, IL 60714-2828 |
Second Address | Crystal Lake, IL 60014-4520 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/07/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00732007 | BLUE SHIELD OF ILLINOIS (01) | IL |
C75640 | (02) | IL |