Provider Demographics
NPI:1487302089
Name:MARCUM, MATTHEW JACOB (DPT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JACOB
Last Name:MARCUM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 BUFFALO RUN CT
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-8104
Mailing Address - Country:US
Mailing Address - Phone:606-483-7660
Mailing Address - Fax:
Practice Address - Street 1:2701 CHESTNUT STATION CT
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-6395
Practice Address - Country:US
Practice Address - Phone:800-335-1060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-13
Last Update Date:2022-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007561225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist