Basic Information
| Provider Information | |||||||||
| NPI: | 1396959672 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATLACK | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | CARMALT | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1746 19TH ST | ||||||||
| Address2: | |||||||||
| City: | CUYAHOGA FALLS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442231846 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 525 EAST MARKET ST | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443092090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303753000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 57.010206 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.