Basic Information
| Provider Information | |||||||||
| NPI: | 1750367256 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROCKMAN | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | EDMAN | ||||||||
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| Credential: | PT | ||||||||
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| OtherLastName: | BROCKMAN | ||||||||
| OtherFirstName: | CHUCK | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 16083 SW UPPER BOONES FERRY RD | ||||||||
| Address2: | STE. 300 | ||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972247736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002198835 | ||||||||
| FaxNumber: | 5036399699 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 NE NEFF RD | ||||||||
| Address2: | STE 202, TAI - CENTRAL OREGON BEND | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977014281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413887738 | ||||||||
| FaxNumber: | 5413120121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2005 | ||||||||
| LastUpdateDate: | 11/01/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 3101 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 1653 | MT | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 912 | NV | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P00952506 | 01 | OR | RR MEDICARE | OTHER | 181409 | 05 | OR | MEDICAID |