Provider Demographics
NPI:1609547009
Name:MD MATT LLC
Entity type:Organization
Organization Name:MD MATT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
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 1:10220 S DOLFIELD RD STE 106
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-3660
Mailing Address - Country:US
Mailing Address - Phone:443-559-4137
Mailing Address - Fax:
Practice Address - Street 1:6401 NEW HAMPSHIRE AVE
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20783-3201
Practice Address - Country:US
Practice Address - Phone:410-364-8194
Practice Address - Fax:410-364-8194
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MD MATT LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-09-24
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD181014604Medicaid
DC062712289Medicaid