Provider Demographics
NPI:1336152446
Name:TOLLEY, MATTHEW RAY (DPM)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RAY
Last Name:TOLLEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 REBECCA LN
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-8005
Mailing Address - Country:US
Mailing Address - Phone:410-486-1148
Mailing Address - Fax:
Practice Address - Street 1:700 GEIPE RD
Practice Address - Street 2:SUITE 260
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21228-4147
Practice Address - Country:US
Practice Address - Phone:410-747-6655
Practice Address - Fax:410-744-0378
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01279213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD76899701OtherBLUE SHIELD
MD76899702OtherBLUE SHIELD
MD76899704OtherBLUE SHIELD
MD76899703OtherBLUE SHIELD
MD76899701OtherBLUE SHIELD
MD0470210001Medicare NSC
MD76899702OtherBLUE SHIELD
MD0470210004Medicare NSC
MD0470210003Medicare NSC
MD76899703OtherBLUE SHIELD
MDS128640YMedicare ID - Type Unspecified
MDCB1030 480031115Medicare PIN