Provider Demographics
NPI: | 1437167350 |
---|---|
Name: | GIEGENGACK, MATTHEW (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | MATTHEW |
Middle Name: | |
Last Name: | GIEGENGACK |
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: | PO BOX 344 |
Mailing Address - Street 2: | |
Mailing Address - City: | WINSTON SALEM |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 27102-0344 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 336-716-2255 |
Mailing Address - Fax: | 336-716-7994 |
Practice Address - Street 1: | MEDICAL CENTER BLVD |
Practice Address - Street 2: | |
Practice Address - City: | WINSTON SALEM |
Practice Address - State: | NC |
Practice Address - Zip Code: | 27157-0001 |
Practice Address - Country: | US |
Practice Address - Phone: | 336-716-2255 |
Practice Address - Fax: | 336-716-7994 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-08-04 |
Last Update Date: | 2010-08-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NC | 2007-01271 | 207W00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207W00000X | Allopathic & Osteopathic Physicians | Ophthalmology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
146GE | Other | BCBS | |
202031 | Other | MEDCOST | |
VA | 1437167350 | Medicaid | |
7387814 | Other | AETNA | |
810583 | Other | PARTNERS | |
WV | 3810010056 | Medicaid | |
NC | 5907662 | Medicaid | |
SC | Q0127B | Medicaid | |
NC | 5907662 | Medicaid |