Provider Demographics
NPI:1053859686
Name:SCHOUTEN, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:SCHOUTEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD CITY
Mailing Address - State:WI
Mailing Address - Zip Code:54013-8509
Mailing Address - Country:US
Mailing Address - Phone:715-977-1278
Mailing Address - Fax:
Practice Address - Street 1:915 3RD ST
Practice Address - Street 2:
Practice Address - City:GLENWOOD CITY
Practice Address - State:WI
Practice Address - Zip Code:54013-8509
Practice Address - Country:US
Practice Address - Phone:715-977-1278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIWZZXZ5784046OtherBLUECROSS BLUESHIELD