Provider Demographics
NPI:1730477480
Name:MERRITT, MATTHEW TYLER (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:TYLER
Last Name:MERRITT
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 1:2709 US HIGHWAY 17
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-3796
Mailing Address - Country:US
Mailing Address - Phone:912-756-5699
Mailing Address - Fax:912-756-5388
Practice Address - Street 1:1000 TOWNE CENTER BLVD
Practice Address - Street 2:SUITE 602
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4052
Practice Address - Country:US
Practice Address - Phone:912-330-0155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-15
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057359898225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA116645Medicare PIN