MEDICARE: MR. TIMOTHY DOUGLAS MATHEWS 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	AT001756	OH

General Provider Information

NPI Number	:	1679549364
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TIMOTHY DOUGLAS MATHEWS ATC

Provider Business Mailing Address
First Line	:	627 HERMAN RD
Second Line	:
City	:	GAHANNA
State	:	OH
Zip	:	43230-9201
Country	:	US
Telephone Number	:	614-855-0764
Fax Number	:

Provider Business Practice Location Address
First Line	:	7600 FODOR RD
Second Line	:
City	:	NEW ALBANY
State	:	OH
Zip	:	43054-8738
Country	:	US
Telephone Number	:	614-855-8339
Fax Number	:	614-855-8328

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

Provider Enumeration Date	:	02/23/2006
Last Update Date	:	07/08/2007

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