Provider Demographics
NPI:1770617235
Name:SERVANT, MICHAEL (MPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SERVANT
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 N LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-1111
Mailing Address - Country:US
Mailing Address - Phone:541-482-9182
Mailing Address - Fax:541-482-9181
Practice Address - Street 1:308 N LAUREL ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-1111
Practice Address - Country:US
Practice Address - Phone:541-482-9182
Practice Address - Fax:541-482-9181
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3323225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORJ918101OtherPACIFIC SOURCE
ORJ918101OtherPACIFIC SOURCE