Provider Demographics
NPI:1861985483
Name:PISCHEK, MATTHEW ROBERTO
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ROBERTO
Last Name:PISCHEK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 545
Mailing Address - Street 2:
Mailing Address - City:SILVERHILL
Mailing Address - State:AL
Mailing Address - Zip Code:36576-0545
Mailing Address - Country:US
Mailing Address - Phone:251-213-1101
Mailing Address - Fax:
Practice Address - Street 1:12440 MAGNOLIA AVE STE 200
Practice Address - Street 2:
Practice Address - City:MAGNOLIA SPRINGS
Practice Address - State:AL
Practice Address - Zip Code:36555-6434
Practice Address - Country:US
Practice Address - Phone:251-965-1773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AL65441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program