=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700059573
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT CHARLES ALEXANDER OTR
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2008
-----------------------------------------------------
Last Update Date | 04/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3100 WASHINGTON RD
-----------------------------------------------------
City | KENOSHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53144-1604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-658-4622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2801 15TH AVE
-----------------------------------------------------
City | SOUTH MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53172-3029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-571-0010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 1241-026
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------