Basic Information
| Provider Information | |||||||||
| NPI: | 1699174821 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACLEOD | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | |||||||||
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| Credential: | DPT | ||||||||
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| OtherLastName: | OSBORNE | ||||||||
| OtherFirstName: | MATTHEW | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 441146 | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301609522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709171935 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1030 GRANT ST SE UNIT 3 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303152015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4045654064 | ||||||||
| FaxNumber: | 6785509303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2014 | ||||||||
| LastUpdateDate: | 05/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT011644 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.