Provider Demographics
NPI:1366966228
Name:MOSOW, MATTHEW JACKSON (PT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JACKSON
Last Name:MOSOW
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 1:810 E SUNFLOWER RD STE 150
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-2800
Mailing Address - Country:US
Mailing Address - Phone:662-843-4990
Mailing Address - Fax:662-843-4954
Practice Address - Street 1:810 E SUNFLOWER RD
Practice Address - Street 2:SUITE 150
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732
Practice Address - Country:US
Practice Address - Phone:662-843-4990
Practice Address - Fax:662-843-4954
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT6261208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation