Provider Demographics
NPI:1447622543
Name:WALSH, MATTHEW SR
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:WALSH
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:985 OLD EAGLE SCHOOL RD
Mailing Address - Street 2:SUITE 515
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-1712
Mailing Address - Country:US
Mailing Address - Phone:610-293-0527
Mailing Address - Fax:
Practice Address - Street 1:985 OLD EAGLE SCHOOL RD
Practice Address - Street 2:SUITE 515
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-1712
Practice Address - Country:US
Practice Address - Phone:610-293-0527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA342930171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2018815OtherNATIONAL PRODUCER NUMMBER