Provider Demographics
NPI:1912922014
Name:CASEY, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:CASEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 CONSORT DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-4439
Mailing Address - Country:US
Mailing Address - Phone:636-386-9224
Mailing Address - Fax:636-386-7679
Practice Address - Street 1:339 CONSORT DR
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-4439
Practice Address - Country:US
Practice Address - Phone:636-386-9224
Practice Address - Fax:636-386-7679
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-115992207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036115992Medicaid
IL036115992Medicaid
IL363117700OtherGROUP TAX ID NUMBER
ILI56219Medicare UPIN