MEDICARE: MR. MATTHEW WAYNE CLARK PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT-09442	OH

General Provider Information

NPI Number	:	1093928921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MATTHEW WAYNE CLARK PT

Provider Business Mailing Address
First Line	:	5547 RAINBOW FALLS DR
Second Line	:
City	:	DUBLIN
State	:	OH
Zip	:	43016-6134
Country	:	US
Telephone Number	:	440-667-8629
Fax Number	:

Provider Business Practice Location Address
First Line	:	755 S PLUM ST
Second Line	:
City	:	MARYSVILLE
State	:	OH
Zip	:	43040-1631
Country	:	US
Telephone Number	:	937-644-8826
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/07/2007
Last Update Date	:	07/08/2007

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