Provider Demographics
NPI:1568648830
Name:MATTERN, JAMES C (DC, PC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:C
Last Name:MATTERN
Suffix:
Gender:M
Credentials:DC, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 CUMBERLAND AVE #D
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-1358
Mailing Address - Country:US
Mailing Address - Phone:765-463-7337
Mailing Address - Fax:765-497-4393
Practice Address - Street 1:1231 CUMBERLAND AVE #D
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1358
Practice Address - Country:US
Practice Address - Phone:765-463-7337
Practice Address - Fax:765-497-4393
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001204A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100232700AMedicaid
IN352009282001OtherANTHEM EIN W/SUFFIX
IN352009282100OtherCARESOURCE MEDICAID MCP
IN08001204AOtherSTATE LICENSE
IN350048296OtherRAILROAD MEDICARE
IN000000092081OtherANTHEM
IN00630OtherANTHEM MEDICAID
IN352009282100OtherCARESOURCE MEDICAID MCP
INT89071Medicare UPIN