Healthcare Provider Details

I. General information

NPI: 1194969675
Provider Name (Legal Business Name): MARK R GERHARD RTT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2009
Last Update Date: 04/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 NORTH AVE
GRAND JUNCTION CO
81501-6428
US

IV. Provider business mailing address

10558 CLYO RD
DAYTON OH
45458-9116
US

V. Phone/Fax

Practice location:
  • Phone: 970-263-5039
  • Fax:
Mailing address:
  • Phone: 937-602-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number3209
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: