Provider Demographics
NPI:1205961745
Name:CRAIG K. MATHESON, D.O., P.L.L.C.
Entity type:Organization
Organization Name:CRAIG K. MATHESON, D.O., P.L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER AND SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:MATHESON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:231-757-2500
Mailing Address - Street 1:821 WEST U.S. HIGHWAY 10
Mailing Address - Street 2:
Mailing Address - City:SCOTTVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49454
Mailing Address - Country:US
Mailing Address - Phone:231-757-2500
Mailing Address - Fax:231-757-9073
Practice Address - Street 1:821 W US HIGHWAY 10 31
Practice Address - Street 2:
Practice Address - City:SCOTTVILLE
Practice Address - State:MI
Practice Address - Zip Code:49454-9601
Practice Address - Country:US
Practice Address - Phone:231-757-2500
Practice Address - Fax:231-757-9073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011416261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICLIAOther23D1038209
MI4615194Medicaid
MI0855301234OtherBLUE CROSS BLUE SHIELD ID
MI0855301234OtherBLUE CROSS BLUE SHIELD ID