Provider Demographics
NPI:1467190736
Name:INGERLISA MATTOCH MD INC
Entity Type:Organization
Organization Name:INGERLISA MATTOCH MD INC
Other - Org Name:TIAGA PATHOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:DR
Authorized Official - First Name:INGERLISA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTOCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-818-6788
Mailing Address - Street 1:PO BOX 7268
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-0268
Mailing Address - Country:US
Mailing Address - Phone:970-663-2742
Mailing Address - Fax:970-667-0847
Practice Address - Street 1:1708 BOISE AVE
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-4204
Practice Address - Country:US
Practice Address - Phone:708-186-7889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-25
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic PathologyGroup - Single Specialty