Basic Information
| Provider Information | |||||||||
| NPI: | 1811429145 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACDOUGALL | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | DOUGLAS | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5827 AUGSBURG CIR | ||||||||
| Address2: | |||||||||
| City: | EAST SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130573050 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 160 E ERIE AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191341011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154275000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2017 | ||||||||
| LastUpdateDate: | 07/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MT213507 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MD469264 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.