MEDICARE: MR. MATTHEW J PETRIDES PA-C

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	363AS0400X	Surgical Physician Assistant	25MP00032400	NJ

General Provider Information

NPI Number	:	1407827496
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MATTHEW J PETRIDES PA-C

Provider Business Mailing Address
First Line	:	1945 STATE ROUTE 33
Second Line	:
City	:	NEPTUNE
State	:	NJ
Zip	:	07753-4859
Country	:	US
Telephone Number	:	732-776-4618
Fax Number	:

Provider Business Practice Location Address
First Line	:	1945 CORLIES AVE
Second Line	:
City	:	NEPTUNE CITY
State	:	NJ
Zip	:	07753-4859
Country	:	US
Telephone Number	:	732-775-5500
Fax Number	:

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

Provider Enumeration Date	:	01/30/2006
Last Update Date	:	11/23/2010

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