MEDICARE: MARY ELLEN CAMPBELL DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	0065781	NY
2	225100000X	Physical Therapist	6716	OR

General Provider Information

NPI Number	:	1336152081
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ELLEN CAMPBELL DPT

Provider Business Mailing Address
First Line	:	36 HAWTHORNE ST
Second Line	:
City	:	MEDFORD
State	:	OR
Zip	:	97504-7114
Country	:	US
Telephone Number	:	541-776-2333
Fax Number	:	541-776-2495

Provider Business Practice Location Address
First Line	:	158 W MAIN
Second Line	:
City	:	EAGLE POINT
State	:	OR
Zip	:	97524
Country	:	US
Telephone Number	:	541-830-0914
Fax Number	:	541-830-0923

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	12/30/2011

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