Provider Demographics
NPI:1588607964
Name:MATTINGLY, MICHAEL JOHN (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:MATTINGLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8573 RELIABLE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686
Mailing Address - Country:US
Mailing Address - Phone:866-898-7139
Mailing Address - Fax:616-975-9824
Practice Address - Street 1:1000 HARRINGTON BLVD
Practice Address - Street 2:
Practice Address - City:MT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043
Practice Address - Country:US
Practice Address - Phone:586-493-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013572207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MM013572OtherBCBS
H06827Medicare UPIN
0N81380001Medicare PIN
MM013572OtherBCBS