Provider Demographics
NPI:1376534719
Name:FARGEN, MATTHEW J (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:FARGEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 766351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:210 E GRAY ST
Practice Address - Street 2:SUITE 700
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3900
Practice Address - Country:US
Practice Address - Phone:502-629-5400
Practice Address - Fax:502-629-5492
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY26382207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000388725OtherANTHEM - NMA
6598354OtherCIGNA / NMA
2742795000OtherPAD - NMA
KYP00299457OtherRRMCR - NMA
IN200520630Medicaid
KY64263825Medicaid
072303OtherSIHO - NMA
KY50023117OtherPASSPORT- NORTON INPATIENT SPECIALISTS
50011338OtherPASSPORT - NMA
KY0998804Medicare PIN
072303OtherSIHO - NMA
KYE01347Medicare UPIN