MEDICARE: KRYSTAL MATESIC

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	225100000X	Physical Therapist	5501009514	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00442694	OTHER	MI	RAILROAD MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	650H230510	OTHER	MI	BCBS

General Provider Information

NPI Number	:	1255352571
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRYSTAL MATESIC

Provider Business Mailing Address
First Line	:	32224 PIERCE ST
Second Line	:
City	:	GARDEN CITY
State	:	MI
Zip	:	48135-3238
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	19701 VERNIER RD
Second Line	:
City	:	HARPER WOODS
State	:	MI
Zip	:	48225-1467
Country	:	US
Telephone Number	:	313-884-8920
Fax Number	:

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

Provider Enumeration Date	:	07/21/2006
Last Update Date	:	04/23/2008

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Practice Location Address:

19701 VERNIER RD
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19701 VERNIER RD , STE 150
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1841222999 — DONALD GARVER M.D.
Practice Location Address:

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1437178480 — ALISA MICHELLE CIOKAJLO
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Directions to “ KRYSTAL MATESIC ” Practice Location

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