Provider Demographics
NPI:1710907993
Name:BUSSE, ROBERT G (PT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:G
Last Name:BUSSE
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 1:4000 N PROVIDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8018
Mailing Address - Country:US
Mailing Address - Phone:920-257-2009
Mailing Address - Fax:920-257-2004
Practice Address - Street 1:2100 D. OMRO ROAD
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904
Practice Address - Country:US
Practice Address - Phone:920-232-4040
Practice Address - Fax:920-232-4042
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3258-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40267200Medicaid
WI650019367OtherRAILROAD MEDICARE
WI650019367OtherRAILROAD MEDICARE
WI000486005Medicare ID - Type Unspecified