Provider Demographics
NPI:1861456097
Name:ROBERTS, MARK E (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:ROBERTS
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 1:4750 LINDLE ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17111-2428
Mailing Address - Country:US
Mailing Address - Phone:717-803-3342
Mailing Address - Fax:717-974-8743
Practice Address - Street 1:4337 UNION DEPOSIT ROAD
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17111-2923
Practice Address - Country:US
Practice Address - Phone:717-971-5940
Practice Address - Fax:717-283-2481
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT006158L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001744349Medicaid