Provider Demographics
NPI:1154412377
Name:KROLL, ROBERT A (PT)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:A
Last Name:KROLL
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 1:3126 N. 104TH ST.
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222
Mailing Address - Country:US
Mailing Address - Phone:414-257-3937
Mailing Address - Fax:414-570-0442
Practice Address - Street 1:8825 S. HOWELL AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154
Practice Address - Country:US
Practice Address - Phone:414-570-0441
Practice Address - Fax:414-570-0442
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2943-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI526590Medicaid
WI526590Medicaid