Provider Demographics
NPI:1609957513
Name:MATULEWSKI, THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:MATULEWSKI
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 1:2100 KEYSTONE AVE
Mailing Address - Street 2:MOB 1ST FLOOR
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-1129
Mailing Address - Country:US
Mailing Address - Phone:610-853-1662
Mailing Address - Fax:610-853-3078
Practice Address - Street 1:2100 KEYSTONE AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-1129
Practice Address - Country:US
Practice Address - Phone:610-853-1662
Practice Address - Fax:610-853-3078
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD016599E208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00733538Medicaid
PAC32067Medicare UPIN
PA153050Medicare ID - Type Unspecified