Provider Demographics
NPI:1356637623
Name:GREGORY, MATTHEW SAMUEL (PT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:SAMUEL
Last Name:GREGORY
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:PO BOX 528
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-0528
Mailing Address - Country:US
Mailing Address - Phone:706-638-3880
Mailing Address - Fax:706-638-3890
Practice Address - Street 1:106 PEARL DR
Practice Address - Street 2:SUITE 104
Practice Address - City:LA FAYETTE
Practice Address - State:GA
Practice Address - Zip Code:30728-7509
Practice Address - Country:US
Practice Address - Phone:706-638-3880
Practice Address - Fax:706-638-3890
Is Sole Proprietor?:No
Enumeration Date:2011-06-24
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0016332255A2300X
GAPT010294225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I656198Medicare PIN