Basic Information
| Provider Information | |||||||||
| NPI: | 1891091385 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CALDWELL | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | M | ||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | RUST | ||||||||
| OtherFirstName: | EMILY | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| 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: | 519 NW DIVISION ST | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970305527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036667644 | ||||||||
| FaxNumber: | 5036749980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2011 | ||||||||
| LastUpdateDate: | 04/28/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 6737 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P01567041 | 01 | OR | RR MEDICARE | OTHER | 500632777 | 05 | OR | MEDICAID |