Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | 038 008466 | IL |
Y | 111NX0800X | Chiropractor Orthopedic Specialist | 038008466 | IL |
NPI | 1134191281 |
---|---|
Provider Name | Dr. Vincent James Kamholtz Roberts |
First Address | Evanston, IL 60202-2353 |
Second Address | Evanston, IL 60202 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/02/2006 |
Last Update Date | 13/09/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4532199 | BLUE CROSS (01) | IL |
U72653 | (02) |