Provider Demographics
NPI:1932180775
Name:VANDERKOOI, MATTHEW J (PT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:J
Last Name:VANDERKOOI
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 1:2639 NEW PINERY RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-1110
Mailing Address - Country:US
Mailing Address - Phone:608-742-9356
Mailing Address - Fax:608-742-9358
Practice Address - Street 1:2639 NEW PINERY RD
Practice Address - Street 2:SUITE 2
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-1110
Practice Address - Country:US
Practice Address - Phone:608-742-9356
Practice Address - Fax:608-742-9358
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5434225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40377900Medicaid
WIP00230916OtherRAILROAD MEDICARE INDIV #
WI40377900Medicaid