Healthcare Provider Details

I. General information

NPI: 1770565558
Provider Name (Legal Business Name): GREGORY MATTHEW NEWELL MSPT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 10/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 RAMSEY AVE SUITE B
GRANTS PASS OR
97527-5808
US

IV. Provider business mailing address

625 RAMSEY AVE SUITE B
GRANTS PASS OR
97527-5808
US

V. Phone/Fax

Practice location:
  • Phone: 541-476-1919
  • Fax: 541-476-1920
Mailing address:
  • Phone: 541-476-1919
  • Fax: 541-476-1920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4205
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier081009-022
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerBLUECROSS BLUESHIELD
# 2
IdentifierP00620265
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerMEDICARE RAILROAD
# 3
Identifier182506
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: