Provider Demographics
NPI:1053594051
Name:WHITESELL, MATTHEW ROBERT (MSA, ATC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ROBERT
Last Name:WHITESELL
Suffix:
Gender:M
Credentials:MSA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S. STATE ST.
Mailing Address - Street 2:ROBERT MORRIS UNIVERSITY
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605
Mailing Address - Country:US
Mailing Address - Phone:847-718-6707
Mailing Address - Fax:312-935-4079
Practice Address - Street 1:401 S STATE ST
Practice Address - Street 2:ROBERT MORRIS UNIVERSITY
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-1229
Practice Address - Country:US
Practice Address - Phone:847-718-6707
Practice Address - Fax:312-935-4079
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-12
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000011562255A2300X
IL0960020692255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer