MEDICARE: MATTHEW THOMAS HENRY MPT

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	PT008256	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285632596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW THOMAS HENRY MPT

Provider Business Mailing Address
First Line	:	113 E. OAK ST.
Second Line	:
City	:	MC RAE
State	:	GA
Zip	:	31055-1550
Country	:	US
Telephone Number	:	229-868-2174
Fax Number	:	229-868-2175

Provider Business Practice Location Address
First Line	:	3051 WATSON BLVD
Second Line	:
City	:	WARNER ROBINS
State	:	GA
Zip	:	31093-8536
Country	:	US
Telephone Number	:	478-953-4563
Fax Number	:	478-953-4564

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

Provider Enumeration Date	:	07/11/2005
Last Update Date	:	08/10/2011

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