Provider Demographics
NPI:1356377360
Name:WARD, MATTHEW RUSSELL (DC)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:RUSSELL
Last Name:WARD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 485
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44061-0485
Mailing Address - Country:US
Mailing Address - Phone:440-974-8557
Mailing Address - Fax:440-255-6337
Practice Address - Street 1:6966 HEISLEY RD
Practice Address - Street 2:SUITE F
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4593
Practice Address - Country:US
Practice Address - Phone:440-974-8557
Practice Address - Fax:440-255-6337
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2782111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2131526Medicaid
OHWA 0877751Medicare ID - Type Unspecified