Healthcare Provider Details

I. General information

NPI: 1689350290
Provider Name (Legal Business Name): MATTHEW C GUMM PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2023
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 TRACY WAY STE 102
CHARLESTON WV
25311-1262
US

IV. Provider business mailing address

400 ASSOCIATION DR STE 102
CHARLESTON WV
25311-1298
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-4900
  • Fax:
Mailing address:
  • Phone: 304-388-1724
  • Fax: 304-388-1721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT003878
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: