MEDICARE: DR. MATTHEW PAUL MELANDER DO

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	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	02003069A	IN

General Provider Information

NPI Number	:	1174561211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW PAUL MELANDER DO

Provider Business Mailing Address
First Line	:	12639 OLD TESSON RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-2786
Country	:	US
Telephone Number	:	314-849-0311
Fax Number	:	314-849-4423

Provider Business Practice Location Address
First Line	:	9323 PHOENIX VILLAGE PKWY
Second Line	:
City	:	O FALLON
State	:	MO
Zip	:	63368-4281
Country	:	US
Telephone Number	:	636-561-5030
Fax Number	:	636-561-5033

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

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	07/18/2019

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