Provider Demographics
NPI:1255394185
Name:MATHIAS, ANN E (DO)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:E
Last Name:MATHIAS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:E
Other - Last Name:BREITWEISER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7751 BYRON CENTER AVE SW
Practice Address - Street 2:SUITE A
Practice Address - City:BYRON CENTER
Practice Address - State:MI
Practice Address - Zip Code:49315-8001
Practice Address - Country:US
Practice Address - Phone:616-878-3321
Practice Address - Fax:616-878-0858
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012832207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1255394185Medicaid
MI0M74460322Medicare PIN
MI1255394185Medicaid
MID16150241Medicare PIN