Provider Demographics
NPI:1285834994
Name:DEMATTIA MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:DEMATTIA MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURE
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:DEMATTIA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:414-431-8536
Mailing Address - Street 1:5500 W VLIET ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-2120
Mailing Address - Country:US
Mailing Address - Phone:414-431-8536
Mailing Address - Fax:414-434-2049
Practice Address - Street 1:5500 W VLIET ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-2120
Practice Address - Country:US
Practice Address - Phone:414-431-8536
Practice Address - Fax:414-434-2049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45995207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H97640Medicare UPIN