Provider Demographics
NPI:1083093207
Name:MAT PRAC GROUP, LLC
Entity Type:Organization
Organization Name:MAT PRAC GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:DAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-681-5752
Mailing Address - Street 1:204 S FLOYD ST
Mailing Address - Street 2:BOX 8
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1208
Mailing Address - Country:US
Mailing Address - Phone:502-681-5752
Mailing Address - Fax:
Practice Address - Street 1:204 S FLOYD ST
Practice Address - Street 2:BOX 8
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1208
Practice Address - Country:US
Practice Address - Phone:502-681-5752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-20
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty