MEDICARE: MATTHEW ANTHONY POLHEMUS PT

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	1142503	TX

General Provider Information

NPI Number	:	1164502837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW ANTHONY POLHEMUS PT

Provider Business Mailing Address
First Line	:	14100 RANCH ROAD 12
Second Line	:	100
City	:	WIMBERLEY
State	:	TX
Zip	:	78676-5354
Country	:	US
Telephone Number	:	512-847-3300
Fax Number	:	512-847-3300

Provider Business Practice Location Address
First Line	:	14100 RANCH ROAD 12
Second Line	:	STE 100
City	:	WIMBERLEY
State	:	TX
Zip	:	78676-5354
Country	:	US
Telephone Number	:	512-847-3300
Fax Number	:	512-847-3314

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

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	03/27/2015

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