=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497644033
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW THOMAS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2025
-----------------------------------------------------
Last Update Date | 06/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2400 LAKESIDE DR SUITE 602F
-----------------------------------------------------
City | LYNCHBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-338-7215
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2122 YORK RD STE 300
-----------------------------------------------------
City | OAK BROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60523-1925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-628-6344
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 2305217193
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------