Provider Demographics
NPI:1417169137
Name:ROOT, MATTHEW STEVEN (AT, ATC)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:STEVEN
Last Name:ROOT
Suffix:
Gender:M
Credentials:AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5383 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44641-9381
Mailing Address - Country:US
Mailing Address - Phone:330-454-1851
Mailing Address - Fax:
Practice Address - Street 1:5383 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:OH
Practice Address - Zip Code:44641-9381
Practice Address - Country:US
Practice Address - Phone:330-454-1851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT-0005572255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer