Healthcare Provider Details

I. General information

NPI: 1659586279
Provider Name (Legal Business Name): CARL P MATTIODA MD AND CHAOMING CHEN MDSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 03/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 W 6TH ST
STREATOR IL
61364-2899
US

IV. Provider business mailing address

104 W 6TH ST
STREATOR IL
61364-2899
US

V. Phone/Fax

Practice location:
  • Phone: 815-673-4363
  • Fax: 815-672-2524
Mailing address:
  • Phone: 815-673-4363
  • Fax: 815-672-2524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VH0002X
TaxonomyHospice and Palliative Medicine (Obstetrics & Gynecology) Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. CARL P MATTIODA
Title or Position: PRESIDENT
Credential: MC
Phone: 815-673-4363