Basic Information
Provider Information | |||||||||
NPI: | 1194786475 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REITSMA MATHIAS | ||||||||
FirstName: | ALEATHA | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 24 FRANK LLOYD WRIGHT DR | ||||||||
Address2: | PO BOX 0446 - LOBBY J | ||||||||
City: | ANN ARBOR | ||||||||
State: | MI | ||||||||
PostalCode: | 481059484 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5301 E HURON RIVER DR | ||||||||
Address2: |   | ||||||||
City: | YPSILANTI | ||||||||
State: | MI | ||||||||
PostalCode: | 481971051 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8773366307 | ||||||||
FaxNumber: | 7347123855 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/28/2006 | ||||||||
LastUpdateDate: | 05/25/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301072313 | MI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 07878 | 01 | IA | BCBS - ER LOCATION | OTHER | 9236800 | 01 | IA | DAKOTACARE | OTHER | 14857 | 01 | IA | AVERA HEALTH PLAN | OTHER | 5682027 | 01 | IA | FIRST HEALTH | OTHER | 49409 | 01 | IA | SIOUX VALLEY HEALTH PLAN | OTHER | H53025 | 01 | IA | COVENTRY HEALTH CARE | OTHER | 04-08715 | 01 | IA | MEDICA | OTHER | 1484964 | 05 | IA |   | MEDICAID | 249977 | 01 | IA | MIDLANDS CHOICE | OTHER | 426038405 | 01 | IA | SELECTFIRST | OTHER | 720911046506 | 01 | IA | PREFERRED ONE | OTHER | 0484964 | 05 | IA |   | MEDICAID |