Healthcare Provider Details

I. General information

NPI: 1396975165
Provider Name (Legal Business Name): MATTHEW KOEBERL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2009
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 WESTERN AVE LAKESHORE RADIOLOGY
MANITOWOC WI
54220
US

IV. Provider business mailing address

2300 WESTERN AVE LAKESHORE RADIOLOGY
MANITOWOC WI
54220
US

V. Phone/Fax

Practice location:
  • Phone: 920-320-3800
  • Fax:
Mailing address:
  • Phone: 414-429-0662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number55016
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: