Provider Demographics
NPI:1457537086
Name:MATT PTASZKIEWICZ MD PC
Entity type:Organization
Organization Name:MATT PTASZKIEWICZ MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:PTASZKIEWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:313-881-2666
Mailing Address - Street 1:19787 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2503
Mailing Address - Country:US
Mailing Address - Phone:313-881-2666
Mailing Address - Fax:313-882-7596
Practice Address - Street 1:19787 MACK AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-2503
Practice Address - Country:US
Practice Address - Phone:313-881-2666
Practice Address - Fax:313-882-7596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074851207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P03230Medicare PIN