Provider Demographics
NPI:1861737769
Name:ADVANCED ORTHOPEDIC PHYSICAL THERAPY, P.C.
Entity type:Organization
Organization Name:ADVANCED ORTHOPEDIC PHYSICAL THERAPY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF PHYSICAL THERAPY/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:541-399-6961
Mailing Address - Street 1:835 SE LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:DUNDEE
Mailing Address - State:OR
Mailing Address - Zip Code:97115-8601
Mailing Address - Country:US
Mailing Address - Phone:541-399-6961
Mailing Address - Fax:
Practice Address - Street 1:700 DEBORAH RD STE 190B
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-2198
Practice Address - Country:US
Practice Address - Phone:541-399-6961
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5105261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
12268250OtherCAQH PROVIDER ID (AS INDIVIDUAL PROVIDER)
OR005727Medicaid