Provider Demographics
NPI:1477125136
Name:RICE, MATTHEW DAVID
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DAVID
Last Name:RICE
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 1:2650 RIDGE AVE STE 1223
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1700
Mailing Address - Country:US
Mailing Address - Phone:847-982-6715
Mailing Address - Fax:847-982-3394
Practice Address - Street 1:5215 N CALIFORNIA AVE STE F804
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-7014
Practice Address - Country:US
Practice Address - Phone:773-907-7750
Practice Address - Fax:773-907-7760
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085008641363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant