Provider Demographics
NPI:1477045284
Name:KNOUSE, MATTHEW RYAN (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RYAN
Last Name:KNOUSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1429 S BANCROFT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-4720
Mailing Address - Country:US
Mailing Address - Phone:172-754-3697
Mailing Address - Fax:
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT82482085R0202X
FLTPME54462085R0202X
PAMT215706208600000X
PAMD4790882085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208600000XAllopathic & Osteopathic PhysiciansSurgery