Healthcare Provider Details

I. General information

NPI: 1760833636
Provider Name (Legal Business Name): RICHARD ALEXANDER MATIASZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2016
Last Update Date: 03/09/2017
Certification Date:
Deactivation Date: 02/02/2017
Reactivation Date: 03/09/2017

III. Provider practice location address

251 EAST HURON STREET
CHICAGO IL
60611
US

IV. Provider business mailing address

676 N ST CLAIR STREET SUITE 600
CHICAGO IL
60611
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-0070
  • Fax: 312-695-0063
Mailing address:
  • Phone: 312-695-0700
  • Fax: 312-695-0063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number125069614
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: