Provider Demographics
NPI:1790897015
Name:HARLOW, THAD G (MPT)
Entity Type:Individual
Prefix:MR
First Name:THAD
Middle Name:G
Last Name:HARLOW
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3126 ALAMEDA ST UNIT 306
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8678
Mailing Address - Country:US
Mailing Address - Phone:709-361-0008
Mailing Address - Fax:
Practice Address - Street 1:1111 CRATER LAKE AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:970-361-0008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8350225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO840999425011OtherROCKY MOUNTAIN HMO NUMBER
COP00376779OtherMEDICARE, RAILROAD
CO840999425OtherTAX ID
COC801602Medicare PIN