Healthcare Provider Details

I. General information

NPI: 1558863803
Provider Name (Legal Business Name): MARY GENEVIEVE MATHEWS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2018
Last Update Date: 12/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 EAST MEDICAL CENTER DR 7TH FLOOR C.S. MOTT CHILDREN'S HOSP RECP 'B'
ANN ARBOR MI
48109-4257
US

IV. Provider business mailing address

3621 S STATE ST
ANN ARBOR MI
48108-1633
US

V. Phone/Fax

Practice location:
  • Phone: 734-936-9814
  • Fax:
Mailing address:
  • Phone: 734-647-5299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704276404
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704276404
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: