Provider Demographics
NPI:1437616562
Name:WILD, ROBERT SCOTT GIFFORD (PT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:SCOTT GIFFORD
Last Name:WILD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 EDWARD CURD LN
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-5791
Mailing Address - Country:US
Mailing Address - Phone:615-791-2630
Mailing Address - Fax:615-791-2639
Practice Address - Street 1:3000 EDWARD CURD LN
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-5791
Practice Address - Country:US
Practice Address - Phone:615-791-2630
Practice Address - Fax:615-791-2639
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12079225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPENDINGMedicaid