Provider Demographics
NPI:1508845207
Name:WAYNE, MATTHEW STEVENSON (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:STEVENSON
Last Name:WAYNE
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 1:21076 BYRON RD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-2915
Mailing Address - Country:US
Mailing Address - Phone:216-844-6338
Mailing Address - Fax:216-844-6338
Practice Address - Street 1:12200 FAIRHILL RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44120-1058
Practice Address - Country:US
Practice Address - Phone:216-844-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-069734207R00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00402008OtherMEDICARE RAILROAD
OH2073672Medicaid
OH414697OtherWELLCARE
OH000000524532OtherANTHEM
OH751025OtherBUCKEYE
OH000000221142OtherUNISON
OH2063672Medicaid
OH5496574OtherAETNA
OH5496574OtherAETNA
OH2063672Medicaid