Healthcare Provider Details

I. General information

NPI: 1245522077
Provider Name (Legal Business Name): MATTHEW ALAN HORNICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2011
Last Update Date: 09/14/2020
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 CEDAR ST
NEW HAVEN CT
06510-3218
US

IV. Provider business mailing address

130 ORCUTT DR
GUILFORD CT
06437-2220
US

V. Phone/Fax

Practice location:
  • Phone: 215-785-2701
  • Fax:
Mailing address:
  • Phone: 215-606-8792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number66486
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT199358
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number66486
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: