Healthcare Provider Details

I. General information

NPI: 1881003572
Provider Name (Legal Business Name): ROBERT GELDERT III OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

473 BUENA VISTA ST
EDWARDSVILLE IL
62025-2072
US

IV. Provider business mailing address

473 BUENA VISTA ST
EDWARDSVILLE IL
62025-2072
US

V. Phone/Fax

Practice location:
  • Phone: 618-830-2666
  • Fax:
Mailing address:
  • Phone: 618-830-2666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056005944
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: