MEDICARE: DR. DAVID N MATISOFF 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	2080P0202X	Pediatric Cardiology Physician	DM040001	MI
2	2080P0202X	Pediatric Cardiology Physician	4301040001	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	350C31064	OTHER	MI	BLUE CROSS BLUE SHIELD
2	7500132	OTHER	MI	PHP
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	40155	OTHER	MI	BLUE CARE NETWORK

General Provider Information

NPI Number	:	1649263633
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID N MATISOFF MD

Provider Business Mailing Address
First Line	:	100 MICHIGAN ST NE
Second Line	:	MC 845
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-2560
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3960 PATIENT CARE DR
Second Line	:	SUITE 113
City	:	LANSING
State	:	MI
Zip	:	48911-4275
Country	:	US
Telephone Number	:	517-484-0004
Fax Number	:	517-484-7241

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

Provider Enumeration Date	:	08/25/2005
Last Update Date	:	02/29/2016

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