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General NPI Number Information
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NPI Number | 1700886660
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Entity Type | Individual
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Provider Name | MATTHEW J MICK M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/21/2005
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Last Update Date | 07/06/2011
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Provider Practice Location Address
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Address Line | 6175 RIVERLAKE BLVD
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City | BARTOW
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State | FL
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Zip | 33830-7754
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Country | US
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Telephone | 414-559-2141
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Fax | 863-646-7292
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Provider Business Mailing Address
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Address Line | 6175 RIVERLAKE BLVD
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City | BARTOW
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State | FL
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Zip | 33830-7754
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Country | US
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Telephone | 414-559-2141
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Fax | 863-646-7292
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | 35056
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 207RI0011X
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Taxonomy Name | Interventional Cardiology Physician
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License Number | 00027578
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License Number State | AL
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