Provider Demographics
NPI:1427380310
Name:GERVASE, MATTHEW C (MPT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:C
Last Name:GERVASE
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:2940 ROLLINGRIDGE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-4231
Practice Address - Country:US
Practice Address - Phone:630-369-4771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-03
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070015330225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212622016Medicare PIN
IL202845072Medicare PIN