Provider Demographics
NPI:1568458685
Name:BURGESS, ROBERT GREGORY (PT)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:GREGORY
Last Name:BURGESS
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 1:3602 COY BURGESS LOOP
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32435-6372
Mailing Address - Country:US
Mailing Address - Phone:803-895-6562
Mailing Address - Fax:
Practice Address - Street 1:431 MEADOWLARK ST
Practice Address - Street 2:20TH MEDICAL GROUP/SGOMY
Practice Address - City:SHAW A F B
Practice Address - State:SC
Practice Address - Zip Code:29152-5019
Practice Address - Country:US
Practice Address - Phone:803-895-6562
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 5584225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist