Provider Demographics
NPI: | 1245209188 |
---|---|
Name: | PULISIC, MATTHEW (DPT MS OCS) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | MATTHEW |
Middle Name: | |
Last Name: | PULISIC |
Suffix: | |
Gender: | M |
Credentials: | DPT MS OCS |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 203 N WASHINGTON HWY |
Mailing Address - Street 2: | |
Mailing Address - City: | ASHLAND |
Mailing Address - State: | VA |
Mailing Address - Zip Code: | 23005-1623 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 804-798-1112 |
Mailing Address - Fax: | 804-798-1171 |
Practice Address - Street 1: | 203 N WASHINGTON HWY |
Practice Address - Street 2: | |
Practice Address - City: | ASHLAND |
Practice Address - State: | VA |
Practice Address - Zip Code: | 23005 |
Practice Address - Country: | US |
Practice Address - Phone: | 804-340-1193 |
Practice Address - Fax: | 804-340-1930 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-03-14 |
Last Update Date: | 2019-10-16 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
VA | 2305003929 | 225100000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
VA | 8941653 | Medicaid | |
VA | 010330483 | Medicaid | |
C06575 | Medicare UPIN | ||
VA | 010330483 | Medicaid | |
C09247 | Medicare UPIN | ||
VA | 650000378 | Medicare PIN |