Provider Demographics
NPI:1649250507
Name:FORTUNE, CAMILLA D (PT)
Entity type:Individual
Prefix:
First Name:CAMILLA
Middle Name:D
Last Name:FORTUNE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 COBURG RD
Mailing Address - Street 2:SLOCUM ORTHOPEDICS PC
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-2433
Mailing Address - Country:US
Mailing Address - Phone:541-485-8111
Mailing Address - Fax:541-342-6379
Practice Address - Street 1:55 COBURG RD
Practice Address - Street 2:SLOCUM ORTHOPEDICS PC
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2433
Practice Address - Country:US
Practice Address - Phone:541-485-8111
Practice Address - Fax:541-342-6379
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4743225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q36697Medicare UPIN
OR138566Medicare UPIN
OR1649250507Medicare PIN