Basic Information
Provider Information | |||||||||
NPI: | 1457648255 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HENTGES | ||||||||
FirstName: | MATTHEW | ||||||||
MiddleName: | JOEL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4800 FRIENDSHIP AVE FL 1 | ||||||||
Address2: |   | ||||||||
City: | PITTSBURGH | ||||||||
State: | PA | ||||||||
PostalCode: | 152241722 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4126887580 | ||||||||
FaxNumber: | 4126819676 | ||||||||
Practice Location | |||||||||
Address1: | 4800 FRIENDSHIP AVE FL 1 | ||||||||
Address2: |   | ||||||||
City: | PITTSBURGH | ||||||||
State: | PA | ||||||||
PostalCode: | 152241722 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4126887580 | ||||||||
FaxNumber: | 4126819676 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/30/2011 | ||||||||
LastUpdateDate: | 10/08/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/08/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | SC006288 | PA | N |   | Podiatric Medicine & Surgery Service Providers | Podiatrist |   | 213ES0131X | SC006288 | PA | N |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery | 213ES0103X | SC006288 | PA | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
ID | Type | State | Issuer | Description | 103032566 | 05 | PA |   | MEDICAID |