Provider Demographics
NPI:1497981161
Name:BRENNAN, MATTHEW P (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:P
Last Name:BRENNAN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 PILOT HOUSE DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-1990
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:10128 W BROAD ST
Practice Address - Street 2:FORUM BUILDING III, SUITE K
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-6761
Practice Address - Country:US
Practice Address - Phone:804-217-9210
Practice Address - Fax:804-217-9213
Is Sole Proprietor?:No
Enumeration Date:2009-06-08
Last Update Date:2011-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11681225100000X
VA2305206387225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9223520OtherAETNA
VAP00826481OtherRAILROAD MEDICARE
VA192953OtherBCBS (PHYSICAL THERAPY)
VA1497981161Medicaid
VA023197T54Medicare PIN
VA192953OtherBCBS (PHYSICAL THERAPY)