Healthcare Provider Details

I. General information

NPI: 1841995545
Provider Name (Legal Business Name): MR. MATTHEW IAN REBEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 VFW PKWY
WEST ROXBURY MA
02132-4927
US

IV. Provider business mailing address

625 GLENWOOD AVE
SYRACUSE NY
13207-1617
US

V. Phone/Fax

Practice location:
  • Phone: 617-323-7700
  • Fax:
Mailing address:
  • Phone: 518-257-2149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number1020274
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: