Provider Demographics
NPI:1437302775
Name:MUSHOLT, BEN PAUL (PT)
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:PAUL
Last Name:MUSHOLT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22499
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97269-2499
Mailing Address - Country:US
Mailing Address - Phone:503-496-0385
Mailing Address - Fax:
Practice Address - Street 1:10600 SE MCLOUGHLIN BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7428
Practice Address - Country:US
Practice Address - Phone:503-496-0385
Practice Address - Fax:866-631-9368
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR04301225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR146486Medicare PIN