Provider Demographics
NPI:1821129495
Name:ROBERTSON, MARK ERIC (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ERIC
Last Name:ROBERTSON
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:PO BOX 590
Mailing Address - Street 2:
Mailing Address - City:RED LODGE
Mailing Address - State:MT
Mailing Address - Zip Code:59068-0590
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 W 21ST STREET
Practice Address - Street 2:
Practice Address - City:RED LODGE
Practice Address - State:MT
Practice Address - Zip Code:59068
Practice Address - Country:US
Practice Address - Phone:406-446-1112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1696225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT10573OtherHOSPITAL #