MEDICARE: MR. MATTHEW JAMES HJERTSTEDT ATC

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	2255A2300X	Athletic Trainer	AT4022	TX

General Provider Information

NPI Number	:	1578709754
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MATTHEW JAMES HJERTSTEDT ATC

Provider Business Mailing Address
First Line	:	6550 SHADY BROOK LN APT 1732
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75206-1224
Country	:	US
Telephone Number	:	214-346-8637
Fax Number	:

Provider Business Practice Location Address
First Line	:	6550 SHADY BROOK LN APT 1732
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75206-1224
Country	:	US
Telephone Number	:	214-346-8637
Fax Number	:

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

Provider Enumeration Date	:	12/18/2008
Last Update Date	:	12/18/2008

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