Provider Demographics
NPI:1356310304
Name:ERNST, MATT JOHN (PT, OCS)
Entity Type:Individual
Prefix:MR
First Name:MATT
Middle Name:JOHN
Last Name:ERNST
Suffix:
Gender:M
Credentials:PT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7567 CENTRAL PARKE BLVD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-6852
Mailing Address - Country:US
Mailing Address - Phone:513-701-6100
Mailing Address - Fax:
Practice Address - Street 1:350 THOMAS MORE PKWY
Practice Address - Street 2:STE 130
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-5465
Practice Address - Country:US
Practice Address - Phone:859-578-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40662251X0800X
OHPT-009584225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0214940Medicaid
OHP00604756OtherMEDICARE RAILROAD
KY00634Medicare PIN
OH366632Medicare PIN
OHP00604756OtherMEDICARE RAILROAD