=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699126946
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW TAYLOR DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2016
-----------------------------------------------------
Last Update Date | 09/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 S CLIFF AVE STE 601
-----------------------------------------------------
City | SIOUX FALLS
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57105-1032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-322-7519
-----------------------------------------------------
Fax | 605-322-4950
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1301 S CLIFF AVE STE 601
-----------------------------------------------------
City | SIOUX FALLS
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57105-1032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-322-7519
-----------------------------------------------------
Fax | 605-322-4950
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | R10724
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 13359
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | 04512
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | 13359
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------