Active NPI
Richard Roberts
- Family Medicine Physician
- Brainerd, MN
National Provider Identifier
1417935479
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 24375
- Practice address
- 2024 S 6TH St
Brainerd, MN 56401-4529 - Phone
- (218) 828-7100
- NPI assigned
- Jan 9, 2006
- Last updated
- Jan 13, 2016
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 24375 | MN | Primary |
Addresses
Primary practice location
2024 S 6TH St
Brainerd, MN 56401-4529
Mailing address
523 N 3Rd St
Brainerd, MN 56401-3054
Phone (218) 829-2861
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 912892100 | Medicaid | MN |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 24375 | MN | MD | Family Medicine Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1136764800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1452643200000",
"number": "1417935479",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "523 N 3RD ST",
"city": "BRAINERD",
"state": "MN",
"postal_code": "564013054",
"telephone_number": "218-829-2861"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2024 S 6TH ST",
"city": "BRAINERD",
"state": "MN",
"postal_code": "564014529",
"telephone_number": "218-828-7100"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ROBERTS",
"first_name": "RICHARD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-01-09",
"last_updated": "2016-01-13",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "MN",
"license": "24375",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "912892100",
"state": "MN"
}
],
"endpoints": [],
"other_names": []
}Other providers in Brainerd, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 13, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.