Provider Demographics
NPI:1831134808
Name:GERBERDING, MARK LEROY (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:LEROY
Last Name:GERBERDING
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 1:1200 W JEFFERSON ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-3694
Mailing Address - Country:US
Mailing Address - Phone:217-726-8502
Mailing Address - Fax:217-726-8568
Practice Address - Street 1:1200 W JEFFERSON ST
Practice Address - Street 2:SUITE D
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-3694
Practice Address - Country:US
Practice Address - Phone:217-726-8502
Practice Address - Fax:217-726-8568
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL70003579225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist