Provider Demographics
NPI:1568470961
Name:GIMPERT, MATTHEW J (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:GIMPERT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 POPLAR ROAD
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-1618
Mailing Address - Country:US
Mailing Address - Phone:770-400-1000
Mailing Address - Fax:
Practice Address - Street 1:745 POPLAR ROAD
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:32605-1618
Practice Address - Country:US
Practice Address - Phone:770-400-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-114640207P00000X, 207R00000X
GA0681652085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08232205OtherBLUE CROSS BLUE SHIELD
GAP01064321OtherRAILROAD MEDICARE
ILP00351066OtherRAILROAD MEDICARE
IL0008232173OtherBLUECROSS BLUESHIELD
GA003125660HMedicaid
I15839Medicare UPIN
ILK30291Medicare PIN