Provider Demographics
NPI:1659449395
Name:RHEINBOLDT, MATTHEW C (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:C
Last Name:RHEINBOLDT
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 1:2799 W. GRAND BLVD
Mailing Address - Street 2:HENRY FORD DEPT OF RADIOLOGY
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2689
Mailing Address - Country:US
Mailing Address - Phone:313-916-7425
Mailing Address - Fax:
Practice Address - Street 1:2799 W. GRAND BLVD
Practice Address - Street 2:HENRY FORD DEPT OF RADIOLOGY
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2689
Practice Address - Country:US
Practice Address - Phone:313-916-7425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0853992085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI473171010Medicaid
700H262300OtherBLUE CROSS-BLUE CROSS
MR085399OtherCHAMPUS-CHAMPUS
MR085399OtherCOMMERCIAL-COMMERCIAL NUMBER
MR085399OtherCHAMPUS-CHAMPUS
MI473171010Medicaid