=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639662190
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTEW MUCHNICK DPT, PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2018
-----------------------------------------------------
Last Update Date | 06/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4730 HAZEL AVE 2R
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-290-8664
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4730 HAZEL AVE REAR 2R
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19143-2056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-290-8664
-----------------------------------------------------
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 | PT025526
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------