1659375483 NPI number — DR. JOHN DAIL MATTHEWS MD

Table of content: DR. JOHN DAIL MATTHEWS MD (NPI 1659375483)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659375483 NPI number — DR. JOHN DAIL MATTHEWS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATTHEWS
Provider First Name:
JOHN
Provider Middle Name:
DAIL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659375483
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1313 CAROLINA ST
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27401-6000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-272-2625
Provider Business Mailing Address Fax Number:
336-275-7507

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1313 CAROLINA STREET
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-272-2625
Provider Business Practice Location Address Fax Number:
336-275-7507
Provider Enumeration Date:
06/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  010132083 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 28666 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10599 . This is a "OPTICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 3954711 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4098004 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 278835 . This is a "MAMSI" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 742 . This is a "PARTNERS PROVIDER #" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 180000348 . This is a "VA MEDICARE PROVIDER #" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 54711 . This is a "BCBS PROVIDER #" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 180025050 . This is a "RR MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 006360033 . This is a "VA MEDICAID PROVIDER #" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 035008 . This is a "ANTHEM BCBS PROVIDER #" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 46637 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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