Healthcare Provider Details

I. General information

NPI: 1821660770
Provider Name (Legal Business Name): MATTHEW RAY ANDERSON PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23770 HOSPITAL ST
CASSOPOLIS MI
49031-9699
US

IV. Provider business mailing address

52465 SANTA MONICA DR
GRANGER IN
46530-9652
US

V. Phone/Fax

Practice location:
  • Phone: 269-445-3801
  • Fax:
Mailing address:
  • Phone: 574-323-3030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502002547
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: