Basic Information
Provider Information | |||||||||
NPI: | 1316038813 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MATSON | ||||||||
FirstName: | ALAN | ||||||||
MiddleName: | HOWARD | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M. D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1121 LAKE COOK RD STE M | ||||||||
Address2: |   | ||||||||
City: | DEERFIELD | ||||||||
State: | IL | ||||||||
PostalCode: | 600155234 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8479454550 | ||||||||
FaxNumber: | 8479488103 | ||||||||
Practice Location | |||||||||
Address1: | 77 N AIRLITE ST | ||||||||
Address2: |   | ||||||||
City: | ELGIN | ||||||||
State: | IL | ||||||||
PostalCode: | 601234912 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8479315694 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/27/2006 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 01067590A | IN | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 036-095385 | IL | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 036095385 | 01 | IL | STATE LICENSE # | OTHER | 036095385 | 05 | IL |   | MEDICAID | BM6262202 | 01 | IL | DEA | OTHER | 200971740A | 05 | IN |   | MEDICAID | 01067590A | 01 | IN | STATE LICENSE | OTHER | 1620188 | 01 | IL | BC/BS | OTHER |