Provider Demographics
NPI:1689658080
Name:MEDLEY, ERIC EUGENE (PT)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:EUGENE
Last Name:MEDLEY
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 1:16083 SW UPPER BOONES FERRY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:702 SW RAMSEY AVE STE 220
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5859
Practice Address - Country:US
Practice Address - Phone:541-479-0765
Practice Address - Fax:541-479-3461
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006236225100000X
OR3573225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR2069033Medicaid
OR104290Medicare PIN