=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194300277
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW WINSTON MOY MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2021
-----------------------------------------------------
Last Update Date | 08/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24 HYDE ST
-----------------------------------------------------
City | WAKEMAN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44889-9301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-839-2226
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11072 BARRINGTON BLVD
-----------------------------------------------------
City | PARMA HEIGHTS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44130-4411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-612-8090
-----------------------------------------------------
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 | 35.149040
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 35.149040
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------