Provider Demographics
NPI:1801080973
Name:JOHN C MATTEUCCI JR MD SC
Entity type:Organization
Organization Name:JOHN C MATTEUCCI JR MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:MATTEUCCI
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:262-653-9221
Mailing Address - Street 1:6127 GREEN BAY ROAD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-2973
Mailing Address - Country:US
Mailing Address - Phone:262-653-9221
Mailing Address - Fax:262-653-9229
Practice Address - Street 1:6127 GREEN BAY ROAD
Practice Address - Street 2:SUITE 600
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2973
Practice Address - Country:US
Practice Address - Phone:262-653-9221
Practice Address - Fax:262-653-9229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-31
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty