Provider Demographics
NPI:1659323871
Name:ROBERTSON, GERAD ANTHONY (PT, ATC)
Entity Type:Individual
Prefix:
First Name:GERAD
Middle Name:ANTHONY
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 E CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:VERMILLION
Mailing Address - State:SD
Mailing Address - Zip Code:57069-2602
Mailing Address - Country:US
Mailing Address - Phone:605-624-7246
Mailing Address - Fax:605-624-7177
Practice Address - Street 1:1407 E CHERRY ST
Practice Address - Street 2:
Practice Address - City:VERMILLION
Practice Address - State:SD
Practice Address - Zip Code:57069-2602
Practice Address - Country:US
Practice Address - Phone:605-624-7246
Practice Address - Fax:605-624-7177
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1271225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD102078Medicare PIN