Provider Demographics
NPI:1073872412
Name:MACELDERRY, ROBERT (PTA)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:MACELDERRY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2362 TWO NOTCH RD.
Mailing Address - Street 2:COLUMBIA REHAB. CLINIC, INC.
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204
Mailing Address - Country:US
Mailing Address - Phone:803-799-7007
Mailing Address - Fax:803-256-8410
Practice Address - Street 1:2362 TWO NOTCH RD.
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204
Practice Address - Country:US
Practice Address - Phone:803-799-7007
Practice Address - Fax:803-256-8410
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-04
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2073225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant