Basic Information
| Provider Information | |||||||||
| NPI: | 1215970926 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SWELSTAD | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2643 PATTERSON RD | ||||||||
| Address2: | SUITE 503 | ||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702452400 | ||||||||
| FaxNumber: | 9702429092 | ||||||||
| Practice Location | |||||||||
| Address1: | 2643 PATTERSON RD | ||||||||
| Address2: | SUITE 503 | ||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702452400 | ||||||||
| FaxNumber: | 9702429092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 06/13/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 45064 | WI | N | Allopathic & Osteopathic Physicians | Plastic Surgery | 2086S0122X | 45750 | CO | Y | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 08101027 | 05 | CO | MEDICAID |