MEDICARE: MATTHEW C SERLO 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	174400000X	Specialist	PT19837	FL
2	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1790894418
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW C SERLO MPT

Provider Business Mailing Address
First Line	:	PO BOX 441146
Second Line	:
City	:	KENNESAW
State	:	GA
Zip	:	30160-9522
Country	:	US
Telephone Number	:	678-403-3632
Fax Number	:	678-567-6737

Provider Business Practice Location Address
First Line	:	236 PONTE VEDRA PARK DR
Second Line	:	SUITE 300
City	:	PONTE VEDRA
State	:	FL
Zip	:	32082-6619
Country	:	US
Telephone Number	:	678-459-3758
Fax Number	:

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

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	05/03/2017

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