Healthcare Provider Details

I. General information

NPI: 1558715417
Provider Name (Legal Business Name): MATTHEW DONALD KORTH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2016
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 E MISSOURI AVE STE 300
PHOENIX AZ
85012-1351
US

IV. Provider business mailing address

645 E MISSOURI AVE STE 300
PHOENIX AZ
85012-1351
US

V. Phone/Fax

Practice location:
  • Phone: 602-262-8900
  • Fax: 602-262-8890
Mailing address:
  • Phone: 602-262-8900
  • Fax: 602-262-8890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number008440
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: