Healthcare Provider Details

I. General information

NPI: 1275734394
Provider Name (Legal Business Name): PHILIP MATICH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4316 CAPAC RD
MUSSEY MI
48014-3108
US

IV. Provider business mailing address

4316 CAPAC RD
MUSSEY MI
48014-3108
US

V. Phone/Fax

Practice location:
  • Phone: 810-395-4375
  • Fax:
Mailing address:
  • Phone: 810-395-4375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPM406642
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: