Provider Demographics
NPI:1922312545
Name:RUPIPER, MATTHEW (PT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:RUPIPER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 N MORTON AVE
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-1426
Mailing Address - Country:US
Mailing Address - Phone:309-266-5488
Mailing Address - Fax:309-266-9144
Practice Address - Street 1:1909 N MORTON AVE
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-1426
Practice Address - Country:US
Practice Address - Phone:309-266-5488
Practice Address - Fax:309-266-9144
Is Sole Proprietor?:No
Enumeration Date:2010-08-06
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00943853OtherRR MEDICARE
ILP00943853OtherRR MEDICARE