Basic Information
| Provider Information | |||||||||
| NPI: | 1831162759 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PROVENCHER | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 181 W MEADOW DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | VAIL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816575242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704761100 | ||||||||
| FaxNumber: | 9704795835 | ||||||||
| Practice Location | |||||||||
| Address1: | 181 W MEADOW DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | VAIL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816575242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704761100 | ||||||||
| FaxNumber: | 9704795835 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 03/07/2016 | ||||||||
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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 | 207XX0005X | 255099 | MA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207XX0005X | 56291 | CO | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
No ID Information.