Provider Demographics
NPI:1538166616
Name:HODROSKY, MATTHEW NICHOLAS (PA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:NICHOLAS
Last Name:HODROSKY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 0446 24 FRANK LLOYD WRIGHT DR. LOBBY J
Mailing Address - Street 2:IHA
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48106
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:734-222-3100
Practice Address - Street 1:5315 ELLIOTT DR STE 304
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-8634
Practice Address - Country:US
Practice Address - Phone:734-712-0655
Practice Address - Fax:734-712-0611
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2017-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004701363AS0400X
OH50002129363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH30466Medicare UPIN
OH78231Medicare ID - Type UnspecifiedMEDICARE