Provider Demographics
NPI:1841336203
Name:ALBERT, MARK (PT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:ALBERT
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 1:1957 THOMPSON RD.
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2031
Mailing Address - Country:US
Mailing Address - Phone:541-266-7050
Mailing Address - Fax:541-266-0180
Practice Address - Street 1:1957 THOMPSON RD.
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2031
Practice Address - Country:US
Practice Address - Phone:541-266-7050
Practice Address - Fax:541-266-0180
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0878225100000X
CA7816225100000X
HI0842225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR291112Medicaid
OR410247401OtherREGENCE BC BS
OR291112Medicaid
OR112599Medicare ID - Type Unspecified