Provider Demographics
NPI:1962020487
Name:BURGE, ROBERT (PTA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:BURGE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 S HOLMEN DR STE 2
Mailing Address - Street 2:
Mailing Address - City:HOLMEN
Mailing Address - State:WI
Mailing Address - Zip Code:54636-9468
Mailing Address - Country:US
Mailing Address - Phone:608-526-9888
Mailing Address - Fax:
Practice Address - Street 1:108 GRANT ST
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:WI
Practice Address - Zip Code:54612-1206
Practice Address - Country:US
Practice Address - Phone:608-323-9998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2729-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant