Provider Demographics
NPI:1619463817
Name:BAUMGART, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BAUMGART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 MIRA MAR AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8546
Mailing Address - Country:US
Mailing Address - Phone:800-848-7868
Mailing Address - Fax:
Practice Address - Street 1:1200 MIRA MAR AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8546
Practice Address - Country:US
Practice Address - Phone:800-848-7868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1478225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist