Basic Information
| Provider Information | |||||||||
| NPI: | 1124002795 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TANK | ||||||||
| FirstName: | ROBERT | ||||||||
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| Credential: | PT, ATC, MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7300 E INDIANA ST | ||||||||
| Address2: | STE 102 | ||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477152794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124760409 | ||||||||
| FaxNumber: | 8124761016 | ||||||||
| Practice Location | |||||||||
| Address1: | 4421 N 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477103621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127593001 | ||||||||
| FaxNumber: | 8124019013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 02/08/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05001580A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 005221 | KY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000000272141 | 01 | IN | BLUE CROSS BLUE SHIELD | OTHER | 200829440 | 05 | IN | MEDICAID | P00019865 | 01 | IN | MEDICARE RAILROAD | OTHER |