Provider Demographics
NPI:1750373783
Name:STOUTENBURG, MATTHEW (PT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:STOUTENBURG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 212
Mailing Address - Street 2:
Mailing Address - City:MENDON
Mailing Address - State:NY
Mailing Address - Zip Code:14506-0212
Mailing Address - Country:US
Mailing Address - Phone:585-582-6085
Mailing Address - Fax:844-638-9546
Practice Address - Street 1:59 PERINTON HILLS SHOPPING CTR
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14445
Practice Address - Country:US
Practice Address - Phone:585-385-0444
Practice Address - Fax:585-385-0442
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024389225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP97362Medicare UPIN
NYAA0447Medicare ID - Type UnspecifiedGROUP NUMBER
NYDD6908Medicare ID - Type UnspecifiedINIDIVIDUAL NUMBER