Healthcare Provider Details

I. General information

NPI: 1770212540
Provider Name (Legal Business Name): MATTHEW B HARRIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2451 W TOUHY AVE
CHICAGO IL
60645-3309
US

IV. Provider business mailing address

1511 W BRYN MAWR AVE APT 2F
CHICAGO IL
60660-4273
US

V. Phone/Fax

Practice location:
  • Phone: 773-338-6800
  • Fax:
Mailing address:
  • Phone: 170-884-6896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.007033
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: