Provider Demographics
NPI:1023554995
Name:ROSS, MATTHEW STEVEN (PTA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:STEVEN
Last Name:ROSS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 33RD ST NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44714-1552
Mailing Address - Country:US
Mailing Address - Phone:330-417-7174
Mailing Address - Fax:
Practice Address - Street 1:2311 NAVE RD SE
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-8822
Practice Address - Country:US
Practice Address - Phone:330-837-1001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-16
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA010688225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH910000533103Medicaid