Basic Information
| Provider Information | |||||||||
| NPI: | 1255607313 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | ROOTJES | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 LIND AVE SW | ||||||||
| Address2: | SUITE 100 ATTN CREDENTIALING | ||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980574970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256902715 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4011 TALBOT RD S STE 500 | ||||||||
| Address2: | |||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980555782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256903488 | ||||||||
| FaxNumber: | 4256909088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2012 | ||||||||
| LastUpdateDate: | 02/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | MD60546813 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207R00000X | MD60546813 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1255607313 | 05 | WA | MEDICAID | 2045532 | 05 | WA | MEDICAID |