Basic Information
| Provider Information | |||||||||
| NPI: | 1205096377 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAPLETON | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | 6307599510 | ||||||||
| Practice Location | |||||||||
| Address1: | 9241 UNIVERSITY BLVD | ||||||||
| Address2: | STE A | ||||||||
| City: | NORTH CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434141140 | ||||||||
| FaxNumber: | 8435532946 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2008 | ||||||||
| LastUpdateDate: | 12/15/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | J10002345 | DE | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | P14235 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1205096377 | 05 | DE | MEDICAID | 1205096377 | 01 | CHAMPUS TRICARE | OTHER | 3527169000 | 01 | AMERIHEALTH IBC | OTHER | 88760501 | 01 | MD | CAREFIRST | OTHER | 5070-0096 | 01 | MD | GHMSI | OTHER |