1669758728 NPI number — PROF. MATTHEW JO GAGE PHD, LAT, ATC

Table of content: PROF. MATTHEW JO GAGE PHD, LAT, ATC (NPI 1669758728)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669758728 NPI number — PROF. MATTHEW JO GAGE PHD, LAT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAGE
Provider First Name:
MATTHEW
Provider Middle Name:
JO
Provider Name Prefix Text:
PROF.
Provider Name Suffix Text:
Provider Credential Text:
PHD, LAT, ATC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669758728
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3552 BRIDLEWOOD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TERRE HAUTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47802-9269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-237-3961
Provider Business Mailing Address Fax Number:
812-237-3615

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1971 UNIVERSITY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LYNCHBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24515-1903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-592-3763
Provider Business Practice Location Address Fax Number:
434-582-7261
Provider Enumeration Date:
11/02/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  0126002093 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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