Provider Demographics
NPI:1336168871
Name:SMALL, MATTHEW G (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:G
Last Name:SMALL
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Gender:M
Credentials:MD
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Mailing Address - Street 1:965 S BAILEY AVE
Mailing Address - Street 2:SUITE 2-1
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-9701
Mailing Address - Country:US
Mailing Address - Phone:269-639-2772
Mailing Address - Fax:269-639-2770
Practice Address - Street 1:965 S BAILEY AVE
Practice Address - Street 2:SUITE 2-1
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-9701
Practice Address - Country:US
Practice Address - Phone:269-639-2772
Practice Address - Fax:269-639-2770
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2016-11-30
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Provider Licenses
StateLicense IDTaxonomies
MI4301083155207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4628853 T10Medicaid
MII17005Medicare UPIN
MIH06003055Medicare ID - Type Unspecified