Healthcare Provider Details

I. General information

NPI: 1326179987
Provider Name (Legal Business Name): MATHEW MCCARTHY, MD, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 08/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 55TH ST
KENOSHA WI
53140-6506
US

IV. Provider business mailing address

5407 8TH AVE
KENOSHA WI
53140-3715
US

V. Phone/Fax

Practice location:
  • Phone: 262-842-0538
  • Fax:
Mailing address:
  • Phone: 262-657-7188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number49892
License Number StateWI

VIII. Authorized Official

Name: DR. MATHEW SEAN MCCARTHY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 262-842-0538