Basic Information
Provider Information | |||||||||
NPI: | 1013123058 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WEICHBRODT | ||||||||
FirstName: | MATTHEW | ||||||||
MiddleName: | THOMAS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 18444 N 25TH AVE | ||||||||
Address2: | STE 310 | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850231266 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6235375600 | ||||||||
FaxNumber: | 8669392673 | ||||||||
Practice Location | |||||||||
Address1: | 10494 W THUNDERBIRD BLVD | ||||||||
Address2: | SUITE 102 | ||||||||
City: | SUN CITY | ||||||||
State: | AZ | ||||||||
PostalCode: | 853513058 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6235375600 | ||||||||
FaxNumber: | 8669392673 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/15/2007 | ||||||||
LastUpdateDate: | 04/24/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 4744 | AZ | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207XS0106X | 4744 | AZ | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XX0801X | 4744 | AZ | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma |
ID Information
ID | Type | State | Issuer | Description | 5550830006 | 01 | AZ | MEDICARE NSC ANTHEM | OTHER | 321626 | 05 | AZ |   | MEDICAID | 5550830010 | 01 | AZ | MEDICARE NSC GILBERT | OTHER | P00688674 | 01 | AZ | RR MEDICARE | OTHER | 5550830004 | 01 | AZ | MEDICARE NSC PV | OTHER | 5550830001 | 01 | AZ | MEDICARE NSC SCW | OTHER | 5550830008 | 01 | AZ | MEDICARE NSC SWV | OTHER | 5550830003 | 01 | AZ | MEDICARE NSC PEORIA | OTHER | 5550830007 | 01 | AZ | MEDICARE NSC DV | OTHER | 5550830009 | 01 | AZ | MEDICARE NSC AZ NORTH | OTHER |