1750809455 NPI number — MATTHEW DWAYNE BLICK PHYSICAL THERAPIST

Table of content: MATTHEW DWAYNE BLICK PHYSICAL THERAPIST (NPI 1750809455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750809455 NPI number — MATTHEW DWAYNE BLICK PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLICK
Provider First Name:
MATTHEW
Provider Middle Name:
DWAYNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
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:
1750809455
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3272
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAGINAW
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48605-3272
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-797-1400
Provider Business Mailing Address Fax Number:
989-797-4077

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
331 E WRIGHT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHEPHERD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48883-8065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-567-1300
Provider Business Practice Location Address Fax Number:
989-567-1301
Provider Enumeration Date:
09/01/2017

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: 225100000X , with the licence number:  5501018295 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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