Provider Demographics
NPI:1275734394
Name:MATICH, PHILIP
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:MATICH
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 1:4316 CAPAC RD
Mailing Address - Street 2:
Mailing Address - City:MUSSEY
Mailing Address - State:MI
Mailing Address - Zip Code:48014-3108
Mailing Address - Country:US
Mailing Address - Phone:810-395-4375
Mailing Address - Fax:
Practice Address - Street 1:4316 CAPAC RD
Practice Address - Street 2:
Practice Address - City:MUSSEY
Practice Address - State:MI
Practice Address - Zip Code:48014-3108
Practice Address - Country:US
Practice Address - Phone:810-395-4375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIPM406642207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIPM406642OtherSTATE LICENSE
MIPM406642OtherSTATE LICENSE
MI0G46043Medicare ID - Type Unspecified