Healthcare Provider Details

I. General information

NPI: 1881045862
Provider Name (Legal Business Name): MATTHEW MARTINEK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 RAND RD STE 120
DES PLAINES IL
60016-2359
US

IV. Provider business mailing address

900 RAND RD STE 120
DES PLAINES IL
60016-2359
US

V. Phone/Fax

Practice location:
  • Phone: 847-823-3185
  • Fax:
Mailing address:
  • Phone: 847-823-3185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085005944
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: