Healthcare Provider Details

I. General information

NPI: 1134520042
Provider Name (Legal Business Name): MATTHEW NEDWICKI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2014
Last Update Date: 10/28/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4771 MICHIGAN AVE
DETROIT MI
48210-3247
US

IV. Provider business mailing address

1416 ERICKSON RD
BOYNE CITY MI
49712-9199
US

V. Phone/Fax

Practice location:
  • Phone: 313-897-2600
  • Fax: 313-897-2424
Mailing address:
  • Phone: 313-618-6824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5601007113
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: