Provider Demographics
NPI:1902239551
Name:GREGORY ROBERTSON, M.D., P.C.
Entity Type:Organization
Organization Name:GREGORY ROBERTSON, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:MC
Authorized Official - Phone:520-319-1455
Mailing Address - Street 1:5240 E KNIGHT DR
Mailing Address - Street 2:SUITE 118
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2122
Mailing Address - Country:US
Mailing Address - Phone:520-319-1455
Mailing Address - Fax:520-316-1454
Practice Address - Street 1:5240 E KNIGHT DR
Practice Address - Street 2:SUITE 118
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2122
Practice Address - Country:US
Practice Address - Phone:520-319-1455
Practice Address - Fax:520-316-1454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-19
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17506208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ296170-004Medicaid
AZE69662Medicare UPIN