Provider Demographics
NPI:1396768305
Name:TIMOTHY J MATTISON, MD INC
Entity type:Organization
Organization Name:TIMOTHY J MATTISON, MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MATTISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-887-5833
Mailing Address - Street 1:PO BOX 638132
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:419-887-5833
Mailing Address - Fax:419-887-5835
Practice Address - Street 1:5757 MONCLOVA RD STE 15
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1863
Practice Address - Country:US
Practice Address - Phone:419-887-5833
Practice Address - Fax:419-887-5835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHDB9527OtherRAILROAD MEDICARE
OH=========-00OtherBWC
OH=========-00OtherBWC
OH9345011Medicare ID - Type Unspecified