Healthcare Provider Details

I. General information

NPI: 1194727420
Provider Name (Legal Business Name): JOHN W MATSESHE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 01/24/2020
Certification Date: 01/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 N HUNT CLUB RD STE 303
GURNEE IL
60031-2603
US

IV. Provider business mailing address

438 FARRINGTON DR
LINCOLNSHIRE IL
60069-2504
US

V. Phone/Fax

Practice location:
  • Phone: 847-855-3150
  • Fax:
Mailing address:
  • Phone: 847-855-3150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036047991
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: