Healthcare Provider Details

I. General information

NPI: 1619924909
Provider Name (Legal Business Name): MATTHEW MACDONALD PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 12/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HOLLAND AVE
BRADDOCK PA
15104-1599
US

IV. Provider business mailing address

1110 VIRGINIA AVE
PITTSBURGH PA
15211-1330
US

V. Phone/Fax

Practice location:
  • Phone: 412-636-5089
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT017198
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: