MEDICARE: DR. MATTHEW JACOB MADER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	2085R0202X	Diagnostic Radiology Physician	76872-20	WI

General Provider Information

NPI Number	:	1578096566
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW JACOB MADER M.D.

Provider Business Mailing Address
First Line	:	9245 MAIN ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64114-3640
Country	:	US
Telephone Number	:	479-619-8963
Fax Number	:

Provider Business Practice Location Address
First Line	:	9245 MAIN ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64114-3640
Country	:	US
Telephone Number	:	479-619-8963
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2017
Last Update Date	:	07/07/2023

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