Provider Demographics
NPI:1093162117
Name:STEWART, SAMUEL
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:STEWART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:423-682-8840
Mailing Address - Fax:423-602-2028
Practice Address - Street 1:1777 COBURG RD STE 3
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-5477
Practice Address - Country:US
Practice Address - Phone:541-505-8041
Practice Address - Fax:541-505-9956
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR61671225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0355693OtherWA L&I
OR500708180Medicaid
OR0355691OtherWA L&I
OR0355692OtherWA L&I
ORR188344Medicare PIN