Provider Demographics
NPI:1619011566
Name:BENNETT, ROBERT HAL JR (MPT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:HAL
Last Name:BENNETT
Suffix:JR
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 1:4611 TILLMAN BLUFF RD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-4965
Mailing Address - Country:US
Mailing Address - Phone:229-219-0700
Mailing Address - Fax:229-219-0702
Practice Address - Street 1:2418 N OAK ST
Practice Address - Street 2:SUITE C
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2576
Practice Address - Country:US
Practice Address - Phone:229-219-0700
Practice Address - Fax:229-219-0702
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007616225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6571Medicare ID - Type Unspecified