Provider Demographics
NPI:1669507596
Name:NELSON, ROBERT O (PT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:O
Last Name:NELSON
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 1:910 SW HIGHWAY 97
Mailing Address - Street 2:MADRAS PHYSICAL THERAPY GROUP, INC, SUITE 200
Mailing Address - City:MADRAS
Mailing Address - State:OR
Mailing Address - Zip Code:97741-9247
Mailing Address - Country:US
Mailing Address - Phone:541-475-2571
Mailing Address - Fax:541-475-2590
Practice Address - Street 1:910 SW HIGHWAY 97
Practice Address - Street 2:MADRAS PHYSICAL THERAPY GROUP, INC, SUITE 200
Practice Address - City:MADRAS
Practice Address - State:OR
Practice Address - Zip Code:97741-9247
Practice Address - Country:US
Practice Address - Phone:541-475-2571
Practice Address - Fax:541-475-2590
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3644225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
059333000OtherBLUE CROSS
OR234859Medicaid
059333000OtherBLUE CROSS