MEDICARE: MATTHEW PAUL HERREMA MS, AT, ATC

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	2255A2300X	Athletic Trainer	2601000708	MI

General Provider Information

NPI Number	:	1396008728
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW PAUL HERREMA MS, AT, ATC

Provider Business Mailing Address
First Line	:	644 SHEFFIELD RD
Second Line	:
City	:	AUBURN HILLS
State	:	MI
Zip	:	48326-3527
Country	:	US
Telephone Number	:	616-780-2134
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 N SQUIRREL RD
Second Line	:
City	:	ROCHESTER
State	:	MI
Zip	:	48309-4402
Country	:	US
Telephone Number	:	248-370-3998
Fax Number	:

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

Provider Enumeration Date	:	06/20/2012
Last Update Date	:	06/20/2012

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