Provider Demographics
NPI:1164502837
Name:POLHEMUS, MATTHEW ANTHONY (PT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ANTHONY
Last Name:POLHEMUS
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 1:14100 RANCH ROAD 12
Mailing Address - Street 2:100
Mailing Address - City:WIMBERLEY
Mailing Address - State:TX
Mailing Address - Zip Code:78676-5354
Mailing Address - Country:US
Mailing Address - Phone:512-847-3300
Mailing Address - Fax:512-847-3300
Practice Address - Street 1:14100 RANCH ROAD 12
Practice Address - Street 2:STE 100
Practice Address - City:WIMBERLEY
Practice Address - State:TX
Practice Address - Zip Code:78676-5354
Practice Address - Country:US
Practice Address - Phone:512-847-3300
Practice Address - Fax:512-847-3314
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1142503225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP83498Medicare UPIN
TXP83498Medicare UPIN