Provider Demographics
NPI:1780322826
Name:MD MATT LLC
Entity type:Organization
Organization Name:MD MATT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-220-6122
Mailing Address - Street 1:625 S CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-4009
Mailing Address - Country:US
Mailing Address - Phone:443-559-4137
Mailing Address - Fax:
Practice Address - Street 1:518 S CAMP MEADE RD STE 5
Practice Address - Street 2:
Practice Address - City:LINTHICUM
Practice Address - State:MD
Practice Address - Zip Code:21090-2766
Practice Address - Country:US
Practice Address - Phone:443-559-4137
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty