Provider Demographics
NPI:1194707042
Name:MEELHUYSEN, EDWIN BENJAMIN (PT)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:BENJAMIN
Last Name:MEELHUYSEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11481 SW HALL BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8403
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-443-1402
Practice Address - Street 1:2728 PHEASANT BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-7589
Practice Address - Country:US
Practice Address - Phone:541-736-8870
Practice Address - Fax:541-736-8860
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2630225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR127048Medicaid
OR107273Medicare ID - Type Unspecified