Healthcare Provider Details

I. General information

NPI: 1174528202
Provider Name (Legal Business Name): MATTHEW BRENDON COLLIGAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 03/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 DOUSMAN ST
GREEN BAY WI
54303-3211
US

IV. Provider business mailing address

1715 DOUSMAN ST
GREEN BAY WI
54303-3211
US

V. Phone/Fax

Practice location:
  • Phone: 920-496-4700
  • Fax:
Mailing address:
  • Phone: 920-496-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberOS9282
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number5101014350
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number63648-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: