Basic Information
| Provider Information | |||||||||
| NPI: | 1902005242 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENRY | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | JACOB | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 95000-6590 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191956590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314656297 | ||||||||
| FaxNumber: | 6314656524 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 PORT WASHINGTON BLVD | ||||||||
| Address2: | SUITE G01 | ||||||||
| City: | ROSLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115761347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166272173 | ||||||||
| FaxNumber: | 5163655813 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2007 | ||||||||
| LastUpdateDate: | 07/14/2014 | ||||||||
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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 | 208G00000X | 265468 | NY | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
No ID Information.