Provider Demographics
NPI:1699750752
Name:EDWARDS, MATTHEW STEVENS (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:STEVENS
Last Name:EDWARDS
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 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-716-0238
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-4151
Practice Address - Fax:336-716-0524
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9601600208600000X, 2086S0102X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7302754Medicaid
NC891333TMedicaid
C5490OtherMEDCOST
7906221OtherAETNA
37162OtherPARTNERS
1333TOtherBCBS
WV2004895000Medicaid
SCQ01601Medicaid
NC2279875CMedicare PIN
NC891333TMedicaid