Provider Demographics
NPI:1588703961
Name:GERLACH, ANTHONY A (MSPT,ATC)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:A
Last Name:GERLACH
Suffix:
Gender:M
Credentials:MSPT,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S EAGLE DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MERRILL
Mailing Address - State:WI
Mailing Address - Zip Code:54452-3716
Mailing Address - Country:US
Mailing Address - Phone:715-539-2740
Mailing Address - Fax:715-536-1814
Practice Address - Street 1:100 S EAGLE DR
Practice Address - Street 2:SUITE 2
Practice Address - City:MERRILL
Practice Address - State:WI
Practice Address - Zip Code:54452-3716
Practice Address - Country:US
Practice Address - Phone:715-539-2740
Practice Address - Fax:715-536-1814
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4991-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40301600Medicaid
52-6567Medicare ID - Type Unspecified