1659586279 NPI number — CARL P MATTIODA MD AND CHAOMING CHEN MDSC

Table of content: (NPI 1659586279)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659586279 NPI number — CARL P MATTIODA MD AND CHAOMING CHEN MDSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARL P MATTIODA MD AND CHAOMING CHEN MDSC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659586279
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 W 6TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STREATOR
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61364-2899
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-673-4363
Provider Business Mailing Address Fax Number:
815-672-2524

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 W 6TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STREATOR
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61364-2899
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-673-4363
Provider Business Practice Location Address Fax Number:
815-672-2524
Provider Enumeration Date:
05/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MATTIODA
Authorized Official First Name:
CARL
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
815-673-4363

Provider Taxonomy Codes

  • Taxonomy code: 207VH0002X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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