Basic Information
| Provider Information | |||||||||
| NPI: | 1568655538 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRAIG | ||||||||
| FirstName: | ROSS | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 560 GAGE BLVD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099423627 | ||||||||
| FaxNumber: | 5099422268 | ||||||||
| Practice Location | |||||||||
| Address1: | 875 SWIFT BLVD | ||||||||
| Address2: | |||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099461654 | ||||||||
| FaxNumber: | 5099435652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2007 | ||||||||
| LastUpdateDate: | 03/28/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00010485 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 009727 | CT | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1568655538 | 05 | WA | MEDICAID |