Basic Information
| Provider Information | |||||||||
| NPI: | 1851375448 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FRIES | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30309 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294170309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435549300 | ||||||||
| FaxNumber: | 8435668780 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 WATSON BLVD | ||||||||
| Address2: | |||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310933431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9122612669 | ||||||||
| FaxNumber: | 9122610561 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 04/29/2008 | ||||||||
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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 | 207ZP0102X | 052247 | GA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 000973244A | 05 | GA | MEDICAID |