Basic Information
| Provider Information | |||||||||
| NPI: | 1770565558 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NEWELL | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | MATTHEW | ||||||||
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| Credential: | MSPT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 RAMSEY AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975275808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414761919 | ||||||||
| FaxNumber: | 5414761920 | ||||||||
| Practice Location | |||||||||
| Address1: | 625 RAMSEY AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975275808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414761919 | ||||||||
| FaxNumber: | 5414761920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 10/16/2008 | ||||||||
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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 | 4205 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 081009-022 | 01 | OR | BLUECROSS BLUESHIELD | OTHER | P00620265 | 01 | OR | MEDICARE RAILROAD | OTHER | 182506 | 05 | OR | MEDICAID |