Basic Information
| Provider Information | |||||||||
| NPI: | 1811020969 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERBST | ||||||||
| FirstName: | MATHEW | ||||||||
| MiddleName: | PATRICK | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 DELAPLAINE CT | ||||||||
| Address2: | ATTN: EDUCATIONAL SERVICES | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151840 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1300 S CENTURY AVE | ||||||||
| Address2: | |||||||||
| City: | WAUNAKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088494315 | ||||||||
| FaxNumber: | 6088501606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 66597-20 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine | 225100000X | 10762-024 | WI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1811020969 | 05 | WI | MEDICAID |