Provider Demographics
NPI:1104025907
Name:WEIGEL, MATTHEW SCOTT (PT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:SCOTT
Last Name:WEIGEL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 N CANYON ST
Mailing Address - Street 2:
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-2320
Mailing Address - Country:US
Mailing Address - Phone:605-642-7996
Mailing Address - Fax:605-642-5955
Practice Address - Street 1:520 N CANYON ST
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-2320
Practice Address - Country:US
Practice Address - Phone:605-642-7996
Practice Address - Fax:605-642-5955
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1629225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1104025907Medicaid
SD1104025907OtherWELLMARK BC/BS
SDS106438Medicare PIN