Provider Demographics
NPI:1760530224
Name:LANDES, ROBERT GOUGH (PT)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:GOUGH
Last Name:LANDES
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 1:1501 MATTHEW LN
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-3738
Mailing Address - Country:US
Mailing Address - Phone:618-993-8223
Mailing Address - Fax:618-549-8827
Practice Address - Street 1:200 N EMERALD LN
Practice Address - Street 2:SUITE 1A
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-2100
Practice Address - Country:US
Practice Address - Phone:618-549-9449
Practice Address - Fax:618-549-8827
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK21864Medicare ID - Type Unspecified