Healthcare Provider Details

I. General information

NPI: 1164981478
Provider Name (Legal Business Name): MATTHEW PLOTT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2019
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 CHAMBLISS AVE NW
CLEVELAND TN
37311-3847
US

IV. Provider business mailing address

2305 CHAMBLISS AVE NW
CLEVELAND TN
37311-3847
US

V. Phone/Fax

Practice location:
  • Phone: 706-264-4603
  • Fax:
Mailing address:
  • Phone: 706-264-4603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number62955
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: