Provider Demographics
NPI:1891080529
Name:CORVALLIS PHYSICAL THERAPY, PC
Entity Type:Organization
Organization Name:CORVALLIS PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:406-375-0980
Mailing Address - Street 1:336 FAIRGROUNDS RD
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840
Mailing Address - Country:US
Mailing Address - Phone:406-375-0980
Mailing Address - Fax:406-375-9938
Practice Address - Street 1:1050 EASTSIDE HWY
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:MT
Practice Address - Zip Code:59828
Practice Address - Country:US
Practice Address - Phone:406-961-3914
Practice Address - Fax:406-363-5271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-10
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM011001245OtherMEDICARE B PIN