Basic Information
| Provider Information | |||||||||
| NPI: | 1932254729 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BETTENDORF | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1615 MAPLE LANE | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156855510 | ||||||||
| FaxNumber: | 7156824022 | ||||||||
| Practice Location | |||||||||
| Address1: | 1615 MAPLE LANE | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156855510 | ||||||||
| FaxNumber: | 7156824022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 05/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 49280 | MN | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 54097-20 | WI | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1932254729 | 05 | WI | MEDICAID | 1932254729 | 05 | MN | MEDICAID |