=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144730888
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW JOHN SPIESS AT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2017
-----------------------------------------------------
Last Update Date | 10/09/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 W SICKLES ST
-----------------------------------------------------
City | SAINT JOHNS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48879-2173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-227-4050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6211 LERNER WAY
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48911-6004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-226-0009
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 2601000901
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------