Provider Demographics
NPI:1437275203
Name:MARALLO, MATTHEW THOMAS (PT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:THOMAS
Last Name:MARALLO
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 1:107 LANCASTER RD
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03581-1427
Mailing Address - Country:US
Mailing Address - Phone:603-466-2296
Mailing Address - Fax:
Practice Address - Street 1:232 MAIN ST
Practice Address - Street 2:
Practice Address - City:GORHAM
Practice Address - State:NH
Practice Address - Zip Code:03581-1500
Practice Address - Country:US
Practice Address - Phone:603-466-5972
Practice Address - Fax:603-466-5974
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2253225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH57401OtherGENESIS REHAB FOR CIGNA
NH1004245OtherANTHEM BCBS
5441373OtherHEALTHCARE VALUE MANAGEME
NHAA63614OtherHARVARD PILGRIM HEALTHCAR
NH30392413Medicaid