Basic Information
Provider Information | |||||||||
NPI: | 1689982605 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MATTUCCI | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | MICHAEL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 520 PHILADELPHIA ST | ||||||||
Address2: |   | ||||||||
City: | INDIANA | ||||||||
State: | PA | ||||||||
PostalCode: | 157013902 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7244637478 | ||||||||
FaxNumber: | 7244630931 | ||||||||
Practice Location | |||||||||
Address1: | 1701 FOWLER AVE | ||||||||
Address2: |   | ||||||||
City: | BERWICK | ||||||||
State: | PA | ||||||||
PostalCode: | 186031463 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5707522925 | ||||||||
FaxNumber: | 5707523190 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/24/2010 | ||||||||
LastUpdateDate: | 09/24/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT002447L | PA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.