MEDICARE: MR. MATTHEW VINCENT GILLANE 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	2251X0800X	Orthopedic Physical Therapist	PT003861L	PA

General Provider Information

NPI Number	:	1972781169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MATTHEW VINCENT GILLANE PT

Provider Business Mailing Address
First Line	:	15 HAMPTON CT
Second Line	:
City	:	BLACKWOOD
State	:	NJ
Zip	:	08012-4567
Country	:	US
Telephone Number	:	215-764-8500
Fax Number	:	215-764-8507

Provider Business Practice Location Address
First Line	:	5008 BALTIMORE AVE
Second Line	:	SUITE 2B PHYSICAL THERAPY
City	:	PHILADELPHIA
State	:	PA
Zip	:	19143-3302
Country	:	US
Telephone Number	:	215-764-8500
Fax Number	:	215-764-8507

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

Provider Enumeration Date	:	02/10/2008
Last Update Date	:	02/10/2008

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