=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033123658
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW G TAYLOR MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2006
-----------------------------------------------------
Last Update Date | 09/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3200 CHANNING WAY STE 205
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404-7546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-535-4580
-----------------------------------------------------
Fax | 208-535-4520
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 277381
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30384-7381
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 51784071205
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 2011018390
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | M12933
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207RC0001X
-----------------------------------------------------
Taxonomy Name | Clinical Cardiac Electrophysiology Physician
-----------------------------------------------------
License Number | M-12933
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------