Provider Demographics
NPI:1215197447
Name:BOYLE, MATHEW JAMES
Entity Type:Individual
Prefix:
First Name:MATHEW
Middle Name:JAMES
Last Name:BOYLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7921 JULIE DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4921
Mailing Address - Country:US
Mailing Address - Phone:269-323-1780
Mailing Address - Fax:269-323-1780
Practice Address - Street 1:7921 JULIE DR
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4921
Practice Address - Country:US
Practice Address - Phone:269-323-1780
Practice Address - Fax:269-323-1780
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF390281086177F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes177F00000XOther Service ProvidersLodging
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6411OtherKALAMAZOO COMMUNITY MENTAL HEALTH