MEDICARE: MR. MATTHEW J WILSON LMT

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	247200000X	Other Technician	MA33164	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C2463	OTHER	FL	BLUE CROSS & BLUE SHIELD

General Provider Information

NPI Number	:	1184892531
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MATTHEW J WILSON LMT

Provider Business Mailing Address
First Line	:	119 BEAL PKWY SE
Second Line	:	SUITE 101
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-5386
Country	:	US
Telephone Number	:	850-598-3633
Fax Number	:

Provider Business Practice Location Address
First Line	:	119 BEAL PKWY SE
Second Line	:	SUITE 101
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-5386
Country	:	US
Telephone Number	:	850-598-3633
Fax Number	:

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

Provider Enumeration Date	:	02/19/2008
Last Update Date	:	02/19/2008

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