MEDICARE: MATTHEW A. MAILLOUX PT, DPT, OCS

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	2305206966	VA

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
2	225579	OTHER	VA	BCBS (PHYSICAL THERAPY)

General Provider Information

NPI Number	:	1730475260
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW A. MAILLOUX PT, DPT, OCS

Provider Business Mailing Address
First Line	:	PO BOX 69030
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21264-9030
Country	:	US
Telephone Number	:	757-873-2302
Fax Number	:	757-873-2306

Provider Business Practice Location Address
First Line	:	7493 RIGHT FLANK RD STE 410
Second Line	:
City	:	MECHANICSVILLE
State	:	VA
Zip	:	23116-3846
Country	:	US
Telephone Number	:	804-569-7091
Fax Number	:	804-569-7094

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

Provider Enumeration Date	:	06/23/2011
Last Update Date	:	04/27/2018

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