Provider Demographics
NPI:1629396536
Name:MATHIS, MICHAEL R (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:MATHIS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:1500 E MEDICAL CENTER DR
Practice Address - Street 2:1H247 UNIVERSITY HOSPITAL
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5048
Practice Address - Country:US
Practice Address - Phone:734-936-4280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-17
Last Update Date:2015-06-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301096347207L00000X
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program