Provider Demographics
NPI:1033473053
Name:MEDLEY, MATTHEW WESLEY (DO)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:WESLEY
Last Name:MEDLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:MATT
Other - Middle Name:WESLEY
Other - Last Name:MEDLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:ATTN: MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7686 GEORGETOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-8101
Practice Address - Country:US
Practice Address - Phone:616-252-8600
Practice Address - Fax:616-252-8660
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101020024207Q00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5101020024OtherOSTEOPATHIC MEDICINE AND SURGERY PHYSICIAN LICENSE
MI5315055607OtherBOARD OF PHARMACY CONTROLLED SUBSTANCE LICENSE
MI5315055607OtherBOARD OF PHARMACY CONTROLLED SUBSTANCE LICENSE