Provider Demographics
NPI:1093218570
Name:GEORGE, MATHEW
Entity Type:Individual
Prefix:
First Name:MATHEW
Middle Name:
Last Name:GEORGE
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 1:43259 VINTNERS PLACE DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314-1334
Mailing Address - Country:US
Mailing Address - Phone:586-215-7911
Mailing Address - Fax:
Practice Address - Street 1:3500 SOUTH BLVD W
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-3973
Practice Address - Country:US
Practice Address - Phone:248-852-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-12
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013098225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist