Basic Information
| Provider Information | |||||||||
| NPI: | 1629296298 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OWENS | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636930 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139815123 | ||||||||
| FaxNumber: | 5139815015 | ||||||||
| Practice Location | |||||||||
| Address1: | 770 W HIGH ST | ||||||||
| Address2: | SUITE 160B | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458013990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199965224 | ||||||||
| FaxNumber: | 4199965276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2007 | ||||||||
| LastUpdateDate: | 07/09/2015 | ||||||||
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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 | 208100000X | 35.092081 | OH | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 2961862 | 05 | OH | MEDICAID |