Basic Information
| Provider Information | |||||||||
| NPI: | 1962515478 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | STRAYER | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3702 NEW VISION DR | ||||||||
| Address2: | BLDG B | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602668210 | ||||||||
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| Practice Location | |||||||||
| Address1: | 442 W HIGH ST | ||||||||
| Address2: | |||||||||
| City: | BRYAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435061681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196364517 | ||||||||
| FaxNumber: | 4196366438 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 10/25/2017 | ||||||||
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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 | PT-5455 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2689952 | 05 | OH | MEDICAID |