Basic Information
| Provider Information | |||||||||
| NPI: | 1821251794 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATCHIN | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | LIRON | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DOCTOR OF OSTEOPATHY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8901 WISCONSIN AVENUE | ||||||||
| Address2: | NNMC - GME BUILDING 10 1ST FLOOR ROOM 1006 | ||||||||
| City: | FPO | ||||||||
| State: | AA | ||||||||
| PostalCode: | 208895600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013198278 | ||||||||
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| Practice Location | |||||||||
| Address1: | CAPTAIN JAMES A. LOVELL FEDERAL HEALTH CARE CENTER | ||||||||
| Address2: | 3001 GREEN BAY ROAD | ||||||||
| City: | NORTH CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476881900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2008 | ||||||||
| LastUpdateDate: | 10/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 2021016045 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 390200000X | VA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.