Healthcare Provider Details

I. General information

NPI: 1821251794
Provider Name (Legal Business Name): BRUCE LIRON MATCHIN DOCTOR OF OSTEOPATHY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 10/28/2021
Certification Date: 10/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CAPTAIN JAMES A. LOVELL FEDERAL HEALTH CARE CENTER 3001 GREEN BAY ROAD
NORTH CHICAGO IL
60064
US

IV. Provider business mailing address

8901 WISCONSIN AVENUE NNMC - GME BUILDING 10 1ST FLOOR ROOM 1006
FPO AA
20889-5600
US

V. Phone/Fax

Practice location:
  • Phone: 847-688-1900
  • Fax:
Mailing address:
  • Phone: 301-319-8278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number2021016045
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: