Basic Information
| Provider Information | |||||||||
| NPI: | 1396726907 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | GEORGE | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3455 HIGHWAY 81 S | ||||||||
| Address2: | |||||||||
| City: | LOGANVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300529138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705540665 | ||||||||
| FaxNumber: | 7705540685 | ||||||||
| Practice Location | |||||||||
| Address1: | 313 NEFF AVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | HARRISONBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 228013495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5404341200 | ||||||||
| FaxNumber: | 5404341203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 12/02/2015 | ||||||||
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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 | 026017 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2305005843 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 02529380 | 05 | NY | MEDICAID |