Basic Information
| Provider Information | |||||||||
| NPI: | 1497192686 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATHEW | ||||||||
| FirstName: | AJAY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 53755 BALDWIN CT | ||||||||
| Address2: | |||||||||
| City: | SHELBY TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483151666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862324298 | ||||||||
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| Practice Location | |||||||||
| Address1: | 303 N HURSTBOURNE PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402225185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024125847 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2013 | ||||||||
| LastUpdateDate: | 05/28/2013 | ||||||||
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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 | 225200000X | 5502003619 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.