Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NR0200X | Radiology | 2192 | OH |
Y | 213ER0200X | Radiology | 2192 | OH |
NPI | 1255402277 |
---|---|
Provider Name | Dr. R. Martin Matiscik |
First Address | Boardman, OH 44512-5007 |
Second Address | Boardman, OH 44512-5007 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/11/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000229020 | ANTHEM (01) | OH |
000000350553 | ANTHEM (01) | OH |
0190270 | (05) | OH |
268261599010 | MEDICAL MUTUAL (01) | OH |
U57034 | (02) | OH |