Provider Demographics
NPI:1205096377
Name:STAPLETON, MATTHEW RICHARD (PT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RICHARD
Last Name:STAPLETON
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 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:9241 UNIVERSITY BLVD
Practice Address - Street 2:STE A
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9349
Practice Address - Country:US
Practice Address - Phone:843-414-1140
Practice Address - Fax:843-553-2946
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ10002345225100000X
NCP14235225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1205096377Medicaid
1205096377OtherCHAMPUS TRICARE
3527169000OtherAMERIHEALTH IBC
MD88760501OtherCAREFIRST
MD5070-0096OtherGHMSI
1205096377OtherCHAMPUS TRICARE
MD88760501OtherCAREFIRST