=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619236064
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW BRAGG CALDWELL MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2012
-----------------------------------------------------
Last Update Date | 03/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22292 US HIGHWAY 72
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35613-2604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-614-2444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22292 US HIGHWAY 72
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35613-2604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-614-2444
-----------------------------------------------------
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 | MD.32665
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------