Provider Demographics
NPI:1073667218
Name:OREGON NEUROSPORT PHYSICAL THERAPY
Entity Type:Organization
Organization Name:OREGON NEUROSPORT PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:BAUM
Authorized Official - Suffix:
Authorized Official - Credentials:BS, CFMT
Authorized Official - Phone:541-998-9988
Mailing Address - Street 1:PO BOX 275
Mailing Address - Street 2:
Mailing Address - City:JUNCTION CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97448-0275
Mailing Address - Country:US
Mailing Address - Phone:541-998-9988
Mailing Address - Fax:541-998-9987
Practice Address - Street 1:680 IVY ST
Practice Address - Street 2:
Practice Address - City:JUNCTION CITY
Practice Address - State:OR
Practice Address - Zip Code:97448-1636
Practice Address - Country:US
Practice Address - Phone:541-998-9988
Practice Address - Fax:541-998-9987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurologyGroup - Single Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR118679Medicare UPIN