Provider Demographics
NPI:1417054487
Name:ROBERTS, CRAIG R (MPT)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:R
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3026 HIDDEN LAKE PT
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-4455
Mailing Address - Country:US
Mailing Address - Phone:270-685-9499
Mailing Address - Fax:270-685-9443
Practice Address - Street 1:1605 SCHERM RD
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-5300
Practice Address - Country:US
Practice Address - Phone:270-685-9499
Practice Address - Fax:270-685-9443
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008190A225100000X
KY005392225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000491496OtherBLUE CROSS BLUE SHIELD
IN200839370Medicaid
IN216070OMedicare PIN
IN255480UMedicare PIN