Provider Demographics
NPI:1083902647
Name:MATSEL, KYLE A (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:A
Last Name:MATSEL
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 E INDIANA ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-2794
Mailing Address - Country:US
Mailing Address - Phone:812-476-0409
Mailing Address - Fax:812-476-1016
Practice Address - Street 1:2121 WILLOW ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-5355
Practice Address - Country:US
Practice Address - Phone:812-882-1141
Practice Address - Fax:812-255-0045
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05010551A225100000X
KY006074225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000730546OtherBLUE CROSS BLUE SHIELD
IN000000730562OtherBLUE CROSS BLUE SHIELD
IN201029970Medicaid
IN000000730562OtherBLUE CROSS BLUE SHIELD
IN201029970Medicaid
INM400051070Medicare PIN