Healthcare Provider Details

I. General information

NPI: 1851492672
Provider Name (Legal Business Name): GREGORY J. MATECHAK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 CHATTAHOOCHEE DR
ROCKMART GA
30153-2023
US

IV. Provider business mailing address

420 E 2ND AVE SUITE 103
ROME GA
30161-3209
US

V. Phone/Fax

Practice location:
  • Phone: 770-684-6100
  • Fax: 770-684-7522
Mailing address:
  • Phone: 706-509-3278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number52992
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: