Basic Information
| Provider Information | |||||||||
| NPI: | 1215372578 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KROLIKOWSKI | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 699 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376840699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234336039 | ||||||||
| FaxNumber: | 4234336060 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 SHERIDAN SQ STE 200 | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232467931 | ||||||||
| FaxNumber: | 4232461906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2013 | ||||||||
| LastUpdateDate: | 08/23/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0102204541 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | 3069 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207R00000X | 3069 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | Q025295 | 05 | TN | MEDICAID | 1215372578 | 05 | VA | MEDICAID |