Provider Demographics
NPI:1932139292
Name:MATTIS, HENRY (MD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:
Last Name:MATTIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 W LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1900
Mailing Address - Country:US
Mailing Address - Phone:618-233-6044
Mailing Address - Fax:618-233-3297
Practice Address - Street 1:340 W LINCOLN ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1900
Practice Address - Country:US
Practice Address - Phone:618-233-6044
Practice Address - Fax:618-233-3297
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036061332207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
2507183OtherSECURE HORIZONS
117064OtherHEALTHLINK
096884OtherHEALTH ALLIANCE
MO16272OtherBCBS MO
1413735OtherUHC
3709969003OtherGHP
C41352OtherMERCY
12475OtherESSENCE
237612OtherWELLCARE
IL0360613321Medicaid
42932OtherCMR
060009692OtherRR MEDICARE
ILP05499Medicare PIN
12475OtherESSENCE
117064OtherHEALTHLINK