Provider Demographics
NPI:1851433635
Name:BLACKWELL, SAMUEL E (PT)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:E
Last Name:BLACKWELL
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 1:735 SW 11TH ST
Mailing Address - Street 2:STE 103
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-2649
Mailing Address - Country:US
Mailing Address - Phone:541-923-1436
Mailing Address - Fax:541-923-1467
Practice Address - Street 1:735 SW 11TH ST
Practice Address - Street 2:STE 103
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-2649
Practice Address - Country:US
Practice Address - Phone:541-923-1436
Practice Address - Fax:541-923-1467
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0908225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR05-4082000OtherBLUE CROSS BLUE SHIELD
OR233502Medicaid
OR05-4082000OtherBLUE CROSS BLUE SHIELD