Healthcare Provider Details

I. General information

NPI: 1538629126
Provider Name (Legal Business Name): MATTHEW FREDERICK WELLES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 GRESHAM DR STE 8630
NORFOLK VA
23507-1904
US

IV. Provider business mailing address

3600 FORBES AVENUE FORBES TOWER PLAZA LEVEL SUITE 140
PITTSBURGH PA
15213
US

V. Phone/Fax

Practice location:
  • Phone: 757-388-6115
  • Fax: 757-275-9998
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD480271
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: