Healthcare Provider Details

I. General information

NPI: 1104276542
Provider Name (Legal Business Name): DR. MATTHEW MACKOWSKY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 01/20/2025
Certification Date: 01/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 WILLIAMSON ST
ELIZABETH NJ
07202-3625
US

IV. Provider business mailing address

379 CAMPUS DR
SOMERSET NJ
08873-1161
US

V. Phone/Fax

Practice location:
  • Phone: 908-994-5738
  • Fax:
Mailing address:
  • Phone: 732-937-8939
  • Fax: 732-418-8372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberMC-2472
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number01092242A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNJ
# 4
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25MA11200600
License Number StateNJ
# 5
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number92472
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: