Basic Information
| Provider Information | |||||||||
| NPI: | 1053621078 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEVINE | ||||||||
| FirstName: | MATHEW | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 NORTHSIDE FORSYTH DR | ||||||||
| Address2: | SUITE 340 | ||||||||
| City: | CUMMING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300416012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708868111 | ||||||||
| FaxNumber: | 7702058539 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 NORTHSIDE FORSYTH DR | ||||||||
| Address2: | SUITE 340 | ||||||||
| City: | CUMMING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300416012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708868111 | ||||||||
| FaxNumber: | 7702058539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2010 | ||||||||
| LastUpdateDate: | 10/12/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | OT013214 | PA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207X00000X | OS015919 | PA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | E-8622 | AR | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 074072 | GA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 003167726B | 05 | GA | MEDICAID | 003167726A | 05 | GA | MEDICAID |