Provider Demographics
NPI:1396723748
Name:MATTISON, RONALD EDWIN (MD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:EDWIN
Last Name:MATTISON
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 1:6005 PARK AVE
Mailing Address - Street 2:SUITE 700
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5202
Mailing Address - Country:US
Mailing Address - Phone:901-527-3391
Mailing Address - Fax:
Practice Address - Street 1:6005 PARK AVE
Practice Address - Street 2:SUITE 700
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5202
Practice Address - Country:US
Practice Address - Phone:901-527-3391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048275208600000X
IL036118870208600000X
TN45847208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL135084OtherHAMP
IL3932056OtherBCBS
IL869299OtherHEALTHLINK
IL036118070Medicaid
IL7210895OtherAETNA
IL320875OtherGHP
IL7210895OtherAETNA