Provider Demographics
NPI:1760546410
Name:STANLEY A. MATERKA, DO PC
Entity Type:Organization
Organization Name:STANLEY A. MATERKA, DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:MATERKA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:586-493-8000
Mailing Address - Street 1:PO BOX 8836
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49518-8836
Mailing Address - Country:US
Mailing Address - Phone:866-898-7139
Mailing Address - Fax:616-975-9824
Practice Address - Street 1:1000 HARRINGTON ST
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2920
Practice Address - Country:US
Practice Address - Phone:586-493-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0155000555OtherBCBS
0155000555OtherBCBS
0P48960Medicare PIN