Provider Demographics
NPI:1063029924
Name:MCCONVILLE, MATHISON
Entity Type:Individual
Prefix:
First Name:MATHISON
Middle Name:
Last Name:MCCONVILLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SHADY LN
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:07419-9778
Mailing Address - Country:US
Mailing Address - Phone:973-362-5241
Mailing Address - Fax:
Practice Address - Street 1:1441 U ST NW APT 602
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20009-3528
Practice Address - Country:US
Practice Address - Phone:973-362-5241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist