Basic Information
| Provider Information | |||||||||
| NPI: | 1164407524 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 EAST MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | CROSBY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564411691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2185467000 | ||||||||
| FaxNumber: | 2185464400 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 EAST MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | CROSBY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564411691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2185467000 | ||||||||
| FaxNumber: | 2185464400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2005 | ||||||||
| LastUpdateDate: | 11/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 43029 | MN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 766188600 | 05 | MN | MEDICAID |