Provider Demographics
NPI:1245209188
Name:PULISIC, MATTHEW (DPT MS OCS)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:PULISIC
Suffix:
Gender:M
Credentials:DPT MS OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 N WASHINGTON HWY
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23005-1623
Mailing Address - Country:US
Mailing Address - Phone:804-798-1112
Mailing Address - Fax:804-798-1171
Practice Address - Street 1:203 N WASHINGTON HWY
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:VA
Practice Address - Zip Code:23005
Practice Address - Country:US
Practice Address - Phone:804-340-1193
Practice Address - Fax:804-340-1930
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305003929225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8941653Medicaid
VA010330483Medicaid
C06575Medicare UPIN
VA010330483Medicaid
C09247Medicare UPIN
VA650000378Medicare PIN