Provider Demographics
NPI:1710966106
Name:CLARK, ROBERT (MPT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:CLARK
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 1:211 EASY ST
Mailing Address - Street 2:SUITE 211
Mailing Address - City:UNIONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15401-3129
Mailing Address - Country:US
Mailing Address - Phone:724-437-8200
Mailing Address - Fax:724-437-6673
Practice Address - Street 1:113 THORNTON RD
Practice Address - Street 2:SUITE D
Practice Address - City:BROWNSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15417-9607
Practice Address - Country:US
Practice Address - Phone:724-785-2853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT010856L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA080702SP8Medicare ID - Type Unspecified
PAQ18963Medicare UPIN