MEDICARE: DALTON MATTHEW O'BRIEN DPT

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	007186	KY

General Provider Information

NPI Number	:	1205359148
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DALTON MATTHEW O'BRIEN DPT

Provider Business Mailing Address
First Line	:	175 S ENGLISH STATION RD STE 218
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40245-4199
Country	:	US
Telephone Number	:	502-882-9379
Fax Number	:	502-805-0526

Provider Business Practice Location Address
First Line	:	6005 TIMBER RIDGE DR
Second Line	:
City	:	PROSPECT
State	:	KY
Zip	:	40059-8134
Country	:	US
Telephone Number	:	502-292-0800
Fax Number	:	502-292-0400

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

Provider Enumeration Date	:	07/24/2017
Last Update Date	:	05/24/2021

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