Provider Demographics
NPI:1558583633
Name:GEORGEON, MATINA J (CRNA)
Entity Type:Individual
Prefix:
First Name:MATINA
Middle Name:J
Last Name:GEORGEON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 MACARTHUR BLVD
Mailing Address - Street 2:ANESTHESIA DEPT
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2901
Mailing Address - Country:US
Mailing Address - Phone:219-836-7040
Mailing Address - Fax:219-513-1127
Practice Address - Street 1:901 MACARTHUR BLVD
Practice Address - Street 2:ANESTHESIA DEPT
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2901
Practice Address - Country:US
Practice Address - Phone:219-836-7040
Practice Address - Fax:219-513-1127
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28125475A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036108031Medicaid
IN200859270Medicaid
OTH000Medicare UPIN
IN200859270Medicaid