Healthcare Provider Details

I. General information

NPI: 1720048853
Provider Name (Legal Business Name): ROBERT CECIL MATTHEWS II CST/CFA/KCSA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

Provider Other Name: R. MATT MATTHEWS II CST/CFA/KCSA

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 AUTUMN GLEN DRIVE
MOUNT WASHINGTON KY
40047-0264
US

IV. Provider business mailing address

PO BOX 264
MOUNT WASHINGTON KY
40047-0264
US

V. Phone/Fax

Practice location:
  • Phone: 520-905-1293
  • Fax:
Mailing address:
  • Phone: 520-905-1293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number93050
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License NumberSA106
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: