Healthcare Provider Details

I. General information

NPI: 1285169557
Provider Name (Legal Business Name): MATTHEW SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2017
Last Update Date: 04/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 TAYLOR ST APT 2
PITTSBURGH PA
15224-1843
US

IV. Provider business mailing address

213 TAYLOR ST APT 2
PITTSBURGH PA
15224-1843
US

V. Phone/Fax

Practice location:
  • Phone: 814-442-7761
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberCPO03720
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCPO03720
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: