Provider Demographics
NPI:1790727501
Name:MATHEW, MARY ANN (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:MATHEW
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 FAIR ST
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:MO
Mailing Address - Zip Code:64601-1225
Mailing Address - Country:US
Mailing Address - Phone:660-646-0022
Mailing Address - Fax:660-646-1553
Practice Address - Street 1:740 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:MO
Practice Address - Zip Code:64601-3042
Practice Address - Country:US
Practice Address - Phone:660-646-0022
Practice Address - Fax:660-646-1553
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1183225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO7332708OtherAETNA
MO485768717Medicaid
MO34255016OtherBLUE CROSS BLUE SHIELD
MOP00246846OtherRAIL ROAD MEDICARE
MO34255016OtherBLUE CROSS BLUE SHIELD
MOQ21563Medicare UPIN