Provider Demographics
NPI:1659586279
Name:CARL P MATTIODA MD AND CHAOMING CHEN MDSC
Entity Type:Organization
Organization Name:CARL P MATTIODA MD AND CHAOMING CHEN MDSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:P
Authorized Official - Last Name:MATTIODA
Authorized Official - Suffix:
Authorized Official - Credentials:MC
Authorized Official - Phone:815-673-4363
Mailing Address - Street 1:104 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364-2899
Mailing Address - Country:US
Mailing Address - Phone:815-673-4363
Mailing Address - Fax:815-672-2524
Practice Address - Street 1:104 W 6TH ST
Practice Address - Street 2:
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-2899
Practice Address - Country:US
Practice Address - Phone:815-673-4363
Practice Address - Fax:815-672-2524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207VH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VH0002XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL259300Medicare ID - Type UnspecifiedCHAOMING CHEN
ILC38432Medicare UPIN
IL258600Medicare ID - Type UnspecifiedCARL P MATTIODA MD
ILD89002Medicare UPIN