MEDICARE: MATTHEW PERCHUK P.T.

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	4033-024	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346356565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW PERCHUK P.T.

Provider Business Mailing Address
First Line	:	101 W BROWN DEER RD
Second Line	:
City	:	BAYSIDE
State	:	WI
Zip	:	53217-2316
Country	:	US
Telephone Number	:	414-446-4469
Fax Number	:

Provider Business Practice Location Address
First Line	:	2626 N WAUWATOSA AVE
Second Line	:
City	:	WAUWATOSA
State	:	WI
Zip	:	53213-1137
Country	:	US
Telephone Number	:	414-774-7794
Fax Number	:	414-607-6971

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

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	07/08/2007

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