Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | 4301065543 | MI |
N | 2081P2900X | Pain Medicine | 4301065543 | MI |
NPI | 1134100415 |
---|---|
Provider Name | Matthew Willman Hettle |
First Address | Flint, MI 48507-3170 |
Second Address | Flint, MI 48507-3170 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/11/2005 |
Last Update Date | 19/09/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0B51156 | GROUP BCBS (01) | MI |
0N45090 | GROUP MEDICARE (01) | |
1215930490 | TYPE 2 NPI (01) | |
4303713 | (05) | MI |
CB0923 | GROUP RAILROAD (01) | |
H17026 | (02) |