Basic Information
Provider Information | |||||||||
NPI: | 1902077605 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MATTHEW MCKNIGHT DPM, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NEW SHARON MEMORIAL CLINIC | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1836 LACKLAND HILL PKWY | ||||||||
Address2: |   | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631463572 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3149890300 | ||||||||
FaxNumber: | 3148101399 | ||||||||
Practice Location | |||||||||
Address1: | 302 S PARK AVE | ||||||||
Address2: |   | ||||||||
City: | NEW SHARON | ||||||||
State: | IA | ||||||||
PostalCode: | 502079771 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6412362008 | ||||||||
FaxNumber: | 6412362031 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/20/2008 | ||||||||
LastUpdateDate: | 06/12/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCKNIGHT | ||||||||
AuthorizedOfficialFirstName: | MATTHEW | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | PHYSICIAN/OWNER | ||||||||
AuthorizedOfficialTelephone: | 6412362008 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MATTHEW MCKNIGHT DPM, P.C. | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DPM | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 00737 | IA | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.