Healthcare Provider Details

I. General information

NPI: 1639388911
Provider Name (Legal Business Name): MATTHEW J PROVENZANO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 E COOLSPRING AVE STE 300
MICHIGAN CITY IN
46360-6312
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 219-878-5032
  • Fax: 219-861-8151
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number01072216A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number36490
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number57.019215
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number01072216A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: