Healthcare Provider Details

I. General information

NPI: 1104874890
Provider Name (Legal Business Name): BURKE MARSHALL SELBST P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 SW EMKAY DR STE 100
BEND OR
97702-3663
US

IV. Provider business mailing address

1475 NW ITHACA AVE
BEND OR
97701-2113
US

V. Phone/Fax

Practice location:
  • Phone: 541-385-3344
  • Fax: 541-312-5256
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4042
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: