Provider Demographics
NPI:1194753129
Name:MADERE, MATTHEW (MPT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MADERE
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11320 INDUSTRIPLEX BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809
Mailing Address - Country:US
Mailing Address - Phone:225-295-8183
Mailing Address - Fax:225-752-2937
Practice Address - Street 1:400 W SAINT FRANCIS ST
Practice Address - Street 2:SUITE C1
Practice Address - City:BRUSLY
Practice Address - State:LA
Practice Address - Zip Code:70719-2283
Practice Address - Country:US
Practice Address - Phone:225-749-8980
Practice Address - Fax:225-749-9096
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06567225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4H186Medicare ID - Type Unspecified