Healthcare Provider Details

I. General information

NPI: 1023689817
Provider Name (Legal Business Name): GAVIN MCBRIDE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2021
Last Update Date: 07/02/2021
Certification Date: 07/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 OVERLOOK TER
MADISON WI
53705-2254
US

IV. Provider business mailing address

13618 SW ROSEMARY LN
TIGARD OR
97223-1525
US

V. Phone/Fax

Practice location:
  • Phone: 608-256-1901
  • Fax:
Mailing address:
  • Phone: 541-645-4458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2251C2600X
TaxonomyCardiopulmonary Physical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: