Provider Demographics
NPI:1801904818
Name:AMICO, ROBERT JOHN (PT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOHN
Last Name:AMICO
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 1:418 WEST CLEVELAND RD
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-9577
Mailing Address - Country:US
Mailing Address - Phone:574-271-8424
Mailing Address - Fax:574-271-8425
Practice Address - Street 1:418 W CLEVELAND RD
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-5638
Practice Address - Country:US
Practice Address - Phone:574-271-8424
Practice Address - Fax:574-271-8425
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05004562A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN150600Medicare ID - Type Unspecified