1114907573 NPI number — DR. MATTHEW G WHITIS MD

Table of content: DR. MATTHEW G WHITIS MD (NPI 1114907573)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114907573 NPI number — DR. MATTHEW G WHITIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITIS
Provider First Name:
MATTHEW
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1114907573
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1229 C AVE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OSKALOOSA
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52577-4246
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-672-3100
Provider Business Mailing Address Fax Number:
641-672-3111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1229 C AVE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OSKALOOSA
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52577-4246
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-672-3100
Provider Business Practice Location Address Fax Number:
641-672-3111
Provider Enumeration Date:
01/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207PE0004X , with the licence number:  26132 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10441 . This is a "IA BC PROVIDER NUMBER" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: P00147874 . This is a "IA RR MEDICARE PROVIDER N" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 1037770 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com