MEDICARE: MRS. ELLEN ROE CRAIG MPT

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	OPT16260

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ08443Z	OTHER		BLUE SHIELD

General Provider Information

NPI Number	:	1629088646
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELLEN ROE CRAIG MPT

Provider Business Mailing Address
First Line	:	91 BUCKBOARD RD
Second Line	:
City	:	NEWCASTLE
State	:	CA
Zip	:	95658-9431
Country	:	US
Telephone Number	:	916-663-3573
Fax Number	:

Provider Business Practice Location Address
First Line	:	2945 BELL ROAD
Second Line	:	#215
City	:	AUBURN
State	:	CA
Zip	:	95603
Country	:	US
Telephone Number	:	916-367-1888
Fax Number	:	530-888-0885

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

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	07/11/2011

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