Provider Demographics
NPI:1215945001
Name:WIISANEN, MATTHEW EVERT (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:EVERT
Last Name:WIISANEN
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 1:2205 MCCALLIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-3230
Mailing Address - Country:US
Mailing Address - Phone:423-508-6733
Mailing Address - Fax:423-508-6744
Practice Address - Street 1:2205 MCCALLIE AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-3230
Practice Address - Country:US
Practice Address - Phone:423-508-6733
Practice Address - Fax:423-508-6744
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND12800207R00000X, 207RC0000X, 207RI0011X
KY42001207R00000X
TN54571207R00000X, 207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN176925100Medicaid
MN110010766Medicare ID - Type Unspecified
MN176925100Medicaid