Provider Demographics
NPI:1558719732
Name:SIEMIAWSKI, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:SIEMIAWSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 INDIAN BOUNDARY RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-1518
Mailing Address - Country:US
Mailing Address - Phone:219-983-1290
Mailing Address - Fax:
Practice Address - Street 1:747 INDIAN BOUNDARY RD
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-1518
Practice Address - Country:US
Practice Address - Phone:219-983-1290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-29
Last Update Date:2016-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26025682A183500000X
IL051297746183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist