Provider Demographics
NPI:1205149267
Name:KOWANTZ, MATTHEW CHARLES (PT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CHARLES
Last Name:KOWANTZ
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 1:240 MAIN ST APT 301
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-5744
Mailing Address - Country:US
Mailing Address - Phone:513-289-9957
Mailing Address - Fax:
Practice Address - Street 1:7575 5 MILE RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45230-4346
Practice Address - Country:US
Practice Address - Phone:513-233-4360
Practice Address - Fax:513-233-4361
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH012942225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000679427OtherANTHEM
OH0225920002Medicare NSC
OHKO4302431Medicare PIN