Provider Demographics
NPI:1417270018
Name:ALEX MATAVERDE MD PC
Entity Type:Organization
Organization Name:ALEX MATAVERDE MD PC
Other - Org Name:NONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:Q
Authorized Official - Last Name:MATAVERDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-336-3180
Mailing Address - Street 1:15101 SOUTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-2697
Mailing Address - Country:US
Mailing Address - Phone:313-336-3180
Mailing Address - Fax:313-593-4648
Practice Address - Street 1:15101 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-2697
Practice Address - Country:US
Practice Address - Phone:313-336-3180
Practice Address - Fax:313-593-4648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-10
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301031512208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1430258Medicaid
MI4301031512OtherLICENSE
MI0827693Medicare UPIN
MI0827693Medicare PIN