Basic Information
| Provider Information | |||||||||
| NPI: | 1417998584 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLAHERTY | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | LEONARD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 636256 | ||||||||
| Address2: | CENTRAL CREDENTIALING | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135855504 | ||||||||
| FaxNumber: | 5135855511 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 PIEDMONT AVE | ||||||||
| Address2: | SUITE 3200 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134758730 | ||||||||
| FaxNumber: | 5134758033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 08/24/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 35082928 | OH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 37855 | KY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084V0102X | 35.082928 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Vascular Neurology |
ID Information
| ID | Type | State | Issuer | Description | 4116803 | 01 | OH | MEDICARE PTAN | OTHER | 2426459 | 05 | OH | MEDICAID |