Healthcare Provider Details

I. General information

NPI: 1417380320
Provider Name (Legal Business Name): MATTHEW RYAN WEISS DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2013
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 PRINTERS PKWY #125
COLORADO SPRINGS CO
80910-6100
US

IV. Provider business mailing address

14518 PHEASANT LN
HOMER GLEN IL
60491-9290
US

V. Phone/Fax

Practice location:
  • Phone: 719-635-8622
  • Fax:
Mailing address:
  • Phone: 708-497-5137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number12340
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: