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1134100415

NPI Code Detail

MEDICARE: MATTHEW WILLMAN HETTLE MD

MEDICARE: MATTHEW WILLMAN HETTLE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208100000X	Physical Medicine & Rehabilitation Physician	4301065543	MI
2	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	4301065543	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	0N45090	OTHER		GROUP MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0B51156	OTHER	MI	GROUP BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	1215930490	OTHER		TYPE 2 NPI
5	CB0923	OTHER		GROUP RAILROAD

General Provider Information

NPI Number	:	1134100415
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW WILLMAN HETTLE MD

Provider Business Mailing Address
First Line	:	4466 W BRISTOL RD
Second Line	:
City	:	FLINT
State	:	MI
Zip	:	48507-3170
Country	:	US
Telephone Number	:	810-733-1200
Fax Number	:	810-733-0688

Provider Business Practice Location Address
First Line	:	4466 W BRISTOL RD
Second Line	:
City	:	FLINT
State	:	MI
Zip	:	48507-3170
Country	:	US
Telephone Number	:	810-733-1200
Fax Number	:	810-733-0688

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2005
Last Update Date	:	09/19/2013

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Directions to “ MATTHEW WILLMAN HETTLE MD” Practice Location

Language	Start Address	Practice Location

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