Provider Demographics
NPI:1235120031
Name:SOUTHEAST PHYSICAL THERAPY, P.C.
Entity Type:Organization
Organization Name:SOUTHEAST PHYSICAL THERAPY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:FEELY
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:503-234-4858
Mailing Address - Street 1:2725 SE STEELE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-4617
Mailing Address - Country:US
Mailing Address - Phone:503-234-4858
Mailing Address - Fax:503-234-3227
Practice Address - Street 1:2725 SE STEELE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-4617
Practice Address - Country:US
Practice Address - Phone:503-234-4858
Practice Address - Fax:503-234-3227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1191261QP2000X
WAPT00002913261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR156257Medicaid
ORR0000CFBZWMedicare PIN