Provider Demographics
NPI:1568054096
Name:HYDE, MATTHEW JOHN
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOHN
Last Name:HYDE
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:WEST PAVILION, ROOM G120
Mailing Address - Street 2:3655 VISTA AVE
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2539
Mailing Address - Country:US
Mailing Address - Phone:314-257-8222
Mailing Address - Fax:314-257-8221
Practice Address - Street 1:1201 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1016
Practice Address - Country:US
Practice Address - Phone:314-257-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020025760363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner