Healthcare Provider Details

I. General information

NPI: 1508845207
Provider Name (Legal Business Name): MATTHEW STEVENSON WAYNE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 12/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12200 FAIRHILL RD
CLEVELAND OH
44120-1058
US

IV. Provider business mailing address

21076 BYRON RD
SHAKER HTS OH
44122-2915
US

V. Phone/Fax

Practice location:
  • Phone: 216-844-6300
  • Fax:
Mailing address:
  • Phone: 216-844-6338
  • Fax: 216-844-6338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number35-069734
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35-069734
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: