Basic Information
| Provider Information | |||||||||
| NPI: | 1962407585 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARLSEN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 NE NEFF RD | ||||||||
| Address2: | STE 200 | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977014281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413823344 | ||||||||
| FaxNumber: | 5413821681 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 NE NEFF RD | ||||||||
| Address2: | STE 200 | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977014281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413823344 | ||||||||
| FaxNumber: | 5413821681 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204C00000X | MD12666 | OR | Y | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine, Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD12666 | 01 | OR | OBME | OTHER | 232504 | 05 | OR | MEDICAID |