Basic Information
| Provider Information | |||||||||
| NPI: | 1093709032 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAYMOND | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | WARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 NOBLE ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997014922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074593500 | ||||||||
| FaxNumber: | 9074593559 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 NOBLE ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997014922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074593500 | ||||||||
| FaxNumber: | 9074593559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2005 | ||||||||
| LastUpdateDate: | 02/22/2013 | ||||||||
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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 | 207Q00000X | 2493 | AK | N | Allopathic & Osteopathic Physicians | Family Medicine | 2083X0100X | 2493 | AK | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine | 2083A0100X | 2493 | AK | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Aerospace Medicine |
ID Information
| ID | Type | State | Issuer | Description | BR6835132 | 01 | DEA | OTHER | MD7344 | 05 | AK | MEDICAID |