Basic Information
| Provider Information | |||||||||
| NPI: | 1114583200 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRODY | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 SAINT JAMES CT | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191063702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9085078859 | ||||||||
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| Practice Location | |||||||||
| Address1: | 925 CHESTNUT ST FL 5 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2673393658 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2019 | ||||||||
| LastUpdateDate: | 05/14/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT027683 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT027683 | 01 | PA | PHYSICAL THERAPY STATE LICENSE | OTHER |