Basic Information
| Provider Information | |||||||||
| NPI: | 1366440224 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTISON | ||||||||
| FirstName: | LALAINE | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 7550 LUCERNE DR | ||||||||
| Address2: | STE 405 | ||||||||
| City: | MIDDLEBURG HTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441306503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402348833 | ||||||||
| FaxNumber: | 4402343313 | ||||||||
| Practice Location | |||||||||
| Address1: | 5757 MONCLOVA RD | ||||||||
| Address2: | STE 25 | ||||||||
| City: | MAUMEE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435371863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194829761 | ||||||||
| FaxNumber: | 4197948296 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 12/12/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 35062263 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | P00146677 | 01 | OH | RAILROAD MEDICARE | OTHER | 000000345516 | 01 | OH | ANTHEM | OTHER | 0258868 | 05 | OH | MEDICAID | 02202 | 01 | OH | PARAMOUNT | OTHER |