Healthcare Provider Details

I. General information

NPI: 1023246550
Provider Name (Legal Business Name): MATTHEW SCOTT PAYNE D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2009
Last Update Date: 01/27/2022
Certification Date: 11/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 CHANNING WAY STE 304
IDAHO FALLS ID
83404-7546
US

IV. Provider business mailing address

PO BOX 742337
ATLANTA GA
30374-2337
US

V. Phone/Fax

Practice location:
  • Phone: 208-535-4580
  • Fax: 208-535-4520
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number000597
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMR-1068
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: