Basic Information
| Provider Information | |||||||||
| NPI: | 1013181361 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUCK ROBERTSHAW | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | MARGARET | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636256 CENTRAL CREDENTIALING | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135855501 | ||||||||
| FaxNumber: | 5135855511 | ||||||||
| Practice Location | |||||||||
| Address1: | 4460 RED BANK RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452272172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134757370 | ||||||||
| FaxNumber: | 5135629098 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2008 | ||||||||
| LastUpdateDate: | 01/10/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35-098241 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 35-098241 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100207640 | 05 | KY | MEDICAID | 201122970 | 05 | IN | MEDICAID | 0066760 | 05 | OH | MEDICAID |