Basic Information
Provider Information | |||||||||
NPI: | 1497717300 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROBERT | ||||||||
FirstName: | CHRISTINE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ROBERT | ||||||||
OtherFirstName: | CHRIS | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PT | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 771 PILOT HOUSE DRIVE | ||||||||
Address2: |   | ||||||||
City: | NEWPORT NEWS | ||||||||
State: | VA | ||||||||
PostalCode: | 23606 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7578732302 | ||||||||
FaxNumber: | 7578732306 | ||||||||
Practice Location | |||||||||
Address1: | 4125 IRONBOUND RD | ||||||||
Address2: | SUITE 100 | ||||||||
City: | WILLIAMSBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 231882666 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7572208383 | ||||||||
FaxNumber: | 7572537833 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/05/2006 | ||||||||
LastUpdateDate: | 01/16/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305203336 | VA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 7292532 | 01 |   | AETNA | OTHER | P00277057 | 01 | VA | RAILROAD MEDICARE | OTHER | 192935 | 01 | VA | BCBS PHYSICAL THERAPY | OTHER | 10090202 | 05 | VA |   | MEDICAID |