Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | 036-141979 | IL |
NPI | 1003890856 |
---|---|
Provider Name | Matthew Swayze |
First Address | Pontiac, MI 48342-2217 |
Second Address | Pontiac, MI 48342-2217 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/12/2005 |
Last Update Date | 16/10/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4610410 | (05) | MI |