Healthcare Provider Details

I. General information

NPI: 1659965176
Provider Name (Legal Business Name): MATTHEW T MCCASKEY HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2021
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2548 LEMAY FERRY RD
SAINT LOUIS MO
63125-3131
US

IV. Provider business mailing address

615 N MAIN ST
O FALLON IL
62269-3704
US

V. Phone/Fax

Practice location:
  • Phone: 314-416-1415
  • Fax: 314-416-1415
Mailing address:
  • Phone: 618-624-4471
  • Fax: 618-215-2169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2018018228
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: