Provider Demographics
NPI:1093604035
Name:PERUMATTATHIL, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PERUMATTATHIL
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 1:2788 CHEEKWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-2472
Mailing Address - Country:US
Mailing Address - Phone:443-942-7070
Mailing Address - Fax:
Practice Address - Street 1:12143 CLARKSVILLE PIKE STE 101
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21029-1565
Practice Address - Country:US
Practice Address - Phone:443-230-5339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-02
Last Update Date:2025-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD30450225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist