Basic Information
| Provider Information | |||||||||
| NPI: | 1497723613 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HIESTAND | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6046 WHIPPLE AVE NW | ||||||||
| Address2: | |||||||||
| City: | NORTH CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447207616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308747165 | ||||||||
| FaxNumber: | 3308747166 | ||||||||
| Practice Location | |||||||||
| Address1: | 10724 STATE ROUTE 212 NE | ||||||||
| Address2: | |||||||||
| City: | BOLIVAR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446128740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308747165 | ||||||||
| FaxNumber: | 3308747166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 02/17/2012 | ||||||||
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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 | 207R00000X | 35070029H | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 35-070029 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2066473 | 05 | OH | MEDICAID |