Provider Demographics
NPI:1356512057
Name:MATTHEW MCKNIGHT DPM, PC
Entity Type:Organization
Organization Name:MATTHEW MCKNIGHT DPM, PC
Other - Org Name:DEER CREEK HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:C
Authorized Official - Last Name:MCKNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:641-236-2008
Mailing Address - Street 1:1836 LACKLAND HILL PKWY
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3572
Mailing Address - Country:US
Mailing Address - Phone:314-989-0300
Mailing Address - Fax:314-810-1399
Practice Address - Street 1:401 1ST AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:IA
Practice Address - Zip Code:52342-2129
Practice Address - Country:US
Practice Address - Phone:641-236-2008
Practice Address - Fax:641-236-2031
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MATTHEW MCKNIGHT DPM, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-20
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00737213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6145050002Medicare NSC