Healthcare Provider Details

I. General information

NPI: 1639664501
Provider Name (Legal Business Name): DR. MATTHEW RUSSELL GAFFNEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2018
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6507 HARRISON AVE UNIT N
CINCINNATI OH
45247-2815
US

IV. Provider business mailing address

6507 HARRISON AVE UNIT N
CINCINNATI OH
45247-2815
US

V. Phone/Fax

Practice location:
  • Phone: 513-981-4242
  • Fax: 513-347-5050
Mailing address:
  • Phone: 513-981-4242
  • Fax: 513-347-5050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125.073310
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35.151292
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.073310
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: