Healthcare Provider Details

I. General information

NPI: 1124324421
Provider Name (Legal Business Name): MATTHEW CHRISTOPHER TAYLOR PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2011
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5450 FORT ST EMERGENCY DEPT
TRENTON MI
48183-4601
US

IV. Provider business mailing address

38935 ANN ARBOR RD CREDENTIALING DEPT
LIVONIA MI
48150-3397
US

V. Phone/Fax

Practice location:
  • Phone: 734-671-3883
  • Fax: 734-467-5500
Mailing address:
  • Phone: 734-805-0488
  • Fax: 866-250-6385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005985
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.003515RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: