Provider Demographics
NPI:1699120501
Name:BOYLAN, MATTHEW THOMAS (DO)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:THOMAS
Last Name:BOYLAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19063 INGLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116-2846
Mailing Address - Country:US
Mailing Address - Phone:440-488-0557
Mailing Address - Fax:
Practice Address - Street 1:29000 CENTER RIDGE RD
Practice Address - Street 2:UH ST. JOHN MEDICAL CENTER
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-5219
Practice Address - Country:US
Practice Address - Phone:440-827-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-28
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.014061207R00000X
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty