Basic Information
| Provider Information | |||||||||
| NPI: | 1023062130 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTISON | ||||||||
| FirstName: | GREGG | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 RANDALLIA DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468054638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603734731 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3707 NEW VISION DRIVE | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468955602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604719466 | ||||||||
| FaxNumber: | 2604845919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 35188 | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 000000092615 | 01 | IN | ANTHEM | OTHER | 2100630 | 05 | OH | MEDICAID | 4074924100 | 05 | MI | MEDICAID | 1554 | 01 | IN | PHP | OTHER |