Provider Demographics
NPI:1013100577
Name:STIDHAM, ROBERT C II
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:C
Last Name:STIDHAM
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 WATER RIDGE PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-4580
Mailing Address - Country:US
Mailing Address - Phone:704-831-5065
Mailing Address - Fax:
Practice Address - Street 1:2919 S ELLSWORTH RD
Practice Address - Street 2:SUITE 111
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85212-2164
Practice Address - Country:US
Practice Address - Phone:704-831-5065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-19
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOT2257225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
117502OtherGROUP PTAN
117307Medicare PIN