Provider Demographics
NPI:1407025497
Name:MAIN, MATTHEW BENJAMIN (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BENJAMIN
Last Name:MAIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 MEDICAL DRIVE
Mailing Address - Street 2:#101
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-2990
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:310 MEDICAL DRIVE
Practice Address - Street 2:#101
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-2990
Practice Address - Country:US
Practice Address - Phone:317-415-6350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN46124207Q00000X
IN01067732A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201075290Medicaid
INM400056705Medicare PIN
INP01212042Medicare PIN