Healthcare Provider Details

I. General information

NPI: 1881780021
Provider Name (Legal Business Name): GEORGE M. MATUSCHAK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 08/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD SUITE 228A
SAINT LOUIS MO
63141-8232
US

IV. Provider business mailing address

621 S NEW BALLAS RD SUITE 228A
SAINT LOUIS MO
63141-8232
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-4966
  • Fax: 314-251-4588
Mailing address:
  • Phone: 314-251-4966
  • Fax: 314-251-4588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberR3H17
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: