1386755163 NPI number — MATRIX MEDICAL LLC

Table of content: (NPI 1386755163)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386755163 NPI number — MATRIX MEDICAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MATRIX MEDICAL LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1386755163
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 E NORTH LN STE 5075
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONSHOHOCKEN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19428-2490
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2468 US HIGHWAY 441/27 STE 513
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRUITLAND PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34731-2154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-343-4402
Provider Business Practice Location Address Fax Number:
800-491-5803
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RUSSALESI
Authorized Official First Name:
WENDY
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF COMPLIANCE OFFICER
Authorized Official Telephone Number:
484-246-9499

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: 2077 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 109316200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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