Provider Demographics
NPI:1881780021
Name:MATUSCHAK, GEORGE M (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:M
Last Name:MATUSCHAK
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 1:621 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 228A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-251-4966
Mailing Address - Fax:314-251-4588
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 228A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-4966
Practice Address - Fax:314-251-4588
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR3H17207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1881780021Medicaid
MO202469409Medicaid
MOP01021649OtherRAILROAD MEDICARE
IL19440524Medicaid
MO133890048Medicare PIN
MO049010247Medicare ID - Type Unspecified
MO1881780021Medicaid
A12431Medicare UPIN