Basic Information
| Provider Information | |||||||||
| NPI: | 1730475260 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAILLOUX | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | PT, DPT, OCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 69030 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212649030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578732302 | ||||||||
| FaxNumber: | 7578732306 | ||||||||
| Practice Location | |||||||||
| Address1: | 7493 RIGHT FLANK RD STE 410 | ||||||||
| Address2: | |||||||||
| City: | MECHANICSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231163846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045697091 | ||||||||
| FaxNumber: | 8045697094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2011 | ||||||||
| LastUpdateDate: | 04/27/2018 | ||||||||
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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 | 2305206966 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1730475260 | 05 | VA | MEDICAID | 225579 | 01 | VA | BCBS (PHYSICAL THERAPY) | OTHER |