Provider Demographics
NPI:1124002795
Name:TANK, ROBERT (PT, ATC, MA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:TANK
Suffix:
Gender:M
Credentials:PT, ATC, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 E INDIANA ST
Mailing Address - Street 2:STE 102
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-2794
Mailing Address - Country:US
Mailing Address - Phone:812-476-0409
Mailing Address - Fax:812-476-1016
Practice Address - Street 1:4421 N 1ST AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-3621
Practice Address - Country:US
Practice Address - Phone:812-759-3001
Practice Address - Fax:812-401-9013
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05001580A225100000X
KY005221225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000272141OtherBLUE CROSS BLUE SHIELD
IN200829440Medicaid
INP00019865OtherMEDICARE RAILROAD
INM400030742Medicare PIN
IN216070GGMedicare PIN