Provider Demographics
NPI:1942234414
Name:THOM, MATTHEW ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:ROBERT
Last Name:THOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:701 UNIVERSITY BLVD E
Mailing Address - Street 2:SUITE 908
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-2086
Mailing Address - Country:US
Mailing Address - Phone:205-344-9393
Mailing Address - Fax:205-759-7744
Practice Address - Street 1:701 UNIVERSITY BLVD E
Practice Address - Street 2:SUITE 908
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-2086
Practice Address - Country:US
Practice Address - Phone:205-344-9393
Practice Address - Fax:205-759-7744
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL30929208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL102I346537OtherMEDICARE
AL129502Medicaid