MEDICARE: MAURI L. MATEYCHAK CRNA

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	367500000X	Certified Registered Nurse Anesthetist	RN149214	GA

General Provider Information

NPI Number	:	1457348294
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAURI L. MATEYCHAK CRNA

Provider Business Mailing Address
First Line	:	1321 ECHO MILL COURT
Second Line	:
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127
Country	:	US
Telephone Number	:	770-645-9181
Fax Number	:	770-645-8455

Provider Business Practice Location Address
First Line	:	1321 ECHO MILL COURT
Second Line	:
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127
Country	:	US
Telephone Number	:	770-645-9181
Fax Number	:	770-645-8455

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

Provider Enumeration Date	:	10/05/2005
Last Update Date	:	07/08/2007

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