Basic Information
| Provider Information | |||||||||
| NPI: | 1083702963 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKILLOP | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | STEPHEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 43667 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322033667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047200599 | ||||||||
| FaxNumber: | 9043764036 | ||||||||
| Practice Location | |||||||||
| Address1: | 836 PRUDENTIAL DR STE 1700 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043980125 | ||||||||
| FaxNumber: | 9043981832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 03/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X | 61263 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207R00000X | ME96218 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0001X | ME96218 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RC0000X | ME96218 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 003547000 | 05 | FL | MEDICAID |