Provider Demographics
NPI:1730189069
Name:CHERBUKOVSKY, GREGORY A (PTA)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:CHERBUKOVSKY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W63N541 HANOVER AVE
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-1917
Mailing Address - Country:US
Mailing Address - Phone:262-375-2195
Mailing Address - Fax:262-375-2273
Practice Address - Street 1:W63N541 HANOVER AVE
Practice Address - Street 2:
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012-1917
Practice Address - Country:US
Practice Address - Phone:262-375-2195
Practice Address - Fax:262-375-2273
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI469-019225200000X
WI718-046225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Not Answered225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40395700Medicaid