1932139292 NPI number — HENRY MATTIS M.D.

Table of content: HENRY MATTIS M.D. (NPI 1932139292)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932139292 NPI number — HENRY MATTIS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATTIS
Provider First Name:
HENRY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1932139292
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
340 W LINCOLN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLEVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62220-1900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-233-6044
Provider Business Mailing Address Fax Number:
618-233-3297

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
340 W LINCOLN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLEVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62220-1900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-233-6044
Provider Business Practice Location Address Fax Number:
618-233-3297
Provider Enumeration Date:
07/03/2006

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: 207RC0000X , with the licence number:  036061332 , 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)

  • Identifier: 2507183 . This is a "SECURE HORIZONS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 117064 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 096884 . This is a "HEALTH ALLIANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 16272 . This is a "BCBS MO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 1413735 . This is a "UHC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3709969003 . This is a "GHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: C41352 . This is a "MERCY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 12475 . This is a "ESSENCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 237612 . This is a "WELLCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0360613321 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 42932 . This is a "CMR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 060009692 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".




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