Provider Demographics
NPI:1376614636
Name:DRS DECHECK AND MATACZYNSKI MD SC
Entity Type:Organization
Organization Name:DRS DECHECK AND MATACZYNSKI MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:DECHECK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-634-6679
Mailing Address - Street 1:3805B SPRING ST
Mailing Address - Street 2:SUITE 250
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53405-1641
Mailing Address - Country:US
Mailing Address - Phone:262-634-6679
Mailing Address - Fax:262-634-7935
Practice Address - Street 1:3805 B SPRING STREET
Practice Address - Street 2:SUITE 250
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405
Practice Address - Country:US
Practice Address - Phone:262-634-6679
Practice Address - Fax:262-634-7935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30593800Medicaid
WI30772700Medicaid
WI0000 90530OtherMEDICARE NUMBER FOR CORPORATION
WI25991OtherLICENSE
WI27946OtherLICENSE
WI30593800Medicaid
WI25991OtherLICENSE
WI30772700Medicaid
WI0000 90530OtherMEDICARE NUMBER FOR CORPORATION