Basic Information
| Provider Information | |||||||||
| NPI: | 1366551327 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GENTILE | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2290 | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542212290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203202591 | ||||||||
| FaxNumber: | 9203205102 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542203712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203203000 | ||||||||
| FaxNumber: | 9203203049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 03/04/2015 | ||||||||
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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 | 207RI0011X | 45443 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 34363100 | 05 | WI | MEDICAID | P00213343 | 01 | WI | RAILROAD MEDICARE | OTHER |