Healthcare Provider Details

I. General information

NPI: 1669454799
Provider Name (Legal Business Name): GEORGIA RUOT MERRIFIELD PT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: GEORGIA RUOT BLESSEY PT

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 NE PENN AVE
BEND OR
97701-4264
US

IV. Provider business mailing address

404 NE PENN AVE
BEND OR
97701-4264
US

V. Phone/Fax

Practice location:
  • Phone: 541-318-7041
  • Fax: 541-388-3711
Mailing address:
  • Phone: 541-318-7041
  • Fax: 541-388-3711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4464
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier5512828
Identifier TypeOTHER
Identifier State
Identifier IssuerFIRST HEALTH
# 2
Identifier231986
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 3
Identifier331489
Identifier TypeOTHER
Identifier State
Identifier IssuerPROVIDENCE
# 4
IdentifierH254806
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerPACIFIC SOURCE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: