Healthcare Provider Details

I. General information

NPI: 1790743268
Provider Name (Legal Business Name): MR. MATTHEW JAMES SPIVEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 05/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 S COLUMBIA RD
GRAND FORKS ND
58201-4036
US

IV. Provider business mailing address

5702 PINEHURST DR
GRAND FORKS ND
58201-2808
US

V. Phone/Fax

Practice location:
  • Phone: 701-780-5270
  • Fax:
Mailing address:
  • Phone: 701-772-3745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR27666
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: