Basic Information
| Provider Information | |||||||||
| NPI: | 1164442844 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MESCHKE | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 308 E CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | ANDOVER | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670028897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3167331331 | ||||||||
| FaxNumber: | 3167334916 | ||||||||
| Practice Location | |||||||||
| Address1: | 308 E CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | ANDOVER | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670028897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3167331331 | ||||||||
| FaxNumber: | 3167334916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 12/14/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0531492 | KS | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | 05-31492 | KS | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200367460L | 05 | KS | MEDICAID | 200367460C | 05 | KS | MEDICAID |