Healthcare Provider Details

I. General information

NPI: 1124022801
Provider Name (Legal Business Name): MATTHEW C REECK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 02/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 W 5TH ST
KETCHUM ID
83340-0000
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-725-2171
  • Fax:
Mailing address:
  • Phone: 208-381-2222
  • Fax: 812-331-0196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number01054306A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberM11887
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: