Provider Demographics
NPI:1477172625
Name:MEDINFOPLATFORMA
Entity Type:Organization
Organization Name:MEDINFOPLATFORMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MYKOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATSYUK
Authorized Official - Suffix:
Authorized Official - Credentials:MD,DPT
Authorized Official - Phone:410-565-2813
Mailing Address - Street 1:29660 CITY CENTER DR APT 4
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2413
Mailing Address - Country:US
Mailing Address - Phone:410-565-2813
Mailing Address - Fax:
Practice Address - Street 1:47 N WEBER RD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-2153
Practice Address - Country:US
Practice Address - Phone:410-565-2813
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-08
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1710470380Medicaid