MEDICARE: DR. COY RANDOLPH MATTHEWS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	36388	NC
2	208000000X	Pediatrics Physician	04-44067	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528028149
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. COY RANDOLPH MATTHEWS MD

Provider Business Mailing Address
First Line	:	800 JEFFERSON ST
Second Line	:	SUITE 116
City	:	WHITEVILLE
State	:	NC
Zip	:	28472-3702
Country	:	US
Telephone Number	:	910-642-2642
Fax Number	:	910-642-3346

Provider Business Practice Location Address
First Line	:	100 W ROSS BLVD STE 1B
Second Line	:
City	:	DODGE CITY
State	:	KS
Zip	:	67801-7217
Country	:	US
Telephone Number	:	620-371-5576
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2006
Last Update Date	:	08/25/2022

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