Healthcare Provider Details

I. General information

NPI: 1245782945
Provider Name (Legal Business Name): MATTHEW L WEINTROB DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2016
Last Update Date: 10/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 E CHICAGO AVE
CHICAGO IL
60611
US

IV. Provider business mailing address

10 LIBERTY SQ BSMT 1
BOSTON MA
02109-5814
US

V. Phone/Fax

Practice location:
  • Phone: 312-951-9700
  • Fax: 312-951-6989
Mailing address:
  • Phone: 617-536-1161
  • Fax: 857-239-9711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070023979
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: