Provider Demographics
NPI:1497977151
Name:MATCZAK, LORI M (RN)
Entity Type:Individual
Prefix:MS
First Name:LORI
Middle Name:M
Last Name:MATCZAK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:843 RISING SUN RD
Mailing Address - Street 2:
Mailing Address - City:TELFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18969-2125
Mailing Address - Country:US
Mailing Address - Phone:215-368-7000
Mailing Address - Fax:
Practice Address - Street 1:3975 CONSHOHOCKEN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-5426
Practice Address - Country:US
Practice Address - Phone:215-879-1000
Practice Address - Fax:215-879-3912
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN261173L163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019272130004Medicaid