Provider Demographics
NPI:1235670126
Name:SHORT, MICHAEL G (BS, C-PED)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:G
Last Name:SHORT
Suffix:
Gender:M
Credentials:BS, C-PED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10117 SE SUNNYSIDE RD.
Mailing Address - Street 2:STE. H
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015
Mailing Address - Country:US
Mailing Address - Phone:503-305-7254
Mailing Address - Fax:
Practice Address - Street 1:10117 SE SUNNYSIDE RD.
Practice Address - Street 2:STE. H
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015
Practice Address - Country:US
Practice Address - Phone:503-305-7254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORCPED4280224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist