Provider Demographics
NPI:1326098690
Name:ROBERTS, CHAD (PT)
Entity Type:Individual
Prefix:MR
First Name:CHAD
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1975
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-1975
Mailing Address - Country:US
Mailing Address - Phone:706-236-2755
Mailing Address - Fax:866-647-2045
Practice Address - Street 1:50 TOWN CT
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-2589
Practice Address - Country:US
Practice Address - Phone:386-313-5974
Practice Address - Fax:866-647-2045
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007632225100000X
FLPT19497225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA975142262AMedicaid
GA975142262CMedicaid
GAP00316287OtherRR MEDICARE
FLHS584YMedicare PIN
GA975142262AMedicaid
GA65BBDMVMedicare PIN