Provider Demographics
NPI:1922265982
Name:ADNAN MATTA MD PC
Entity Type:Organization
Organization Name:ADNAN MATTA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ADNAN
Authorized Official - Middle Name:HALIM
Authorized Official - Last Name:MATTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-914-4703
Mailing Address - Street 1:835 MASON ST STE D140
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2256
Mailing Address - Country:US
Mailing Address - Phone:313-914-4703
Mailing Address - Fax:313-438-0148
Practice Address - Street 1:835 MASON ST STE D140
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2256
Practice Address - Country:US
Practice Address - Phone:313-914-4703
Practice Address - Fax:313-438-0148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010343892086S0129X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101701996Medicaid
MI0206353551OtherBCBS
MI101701996Medicaid
MI0P57350Medicare PIN
MI=========OtherCOMMERCIAL