Basic Information
| Provider Information | |||||||||
| NPI: | 1255312302 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SEVENSMA | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | WARREN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5900 BYRON CENTER AVE SW | ||||||||
| Address2: | MEDICAL ADMINISTRATION | ||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495199606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162523243 | ||||||||
| FaxNumber: | 6162520260 | ||||||||
| Practice Location | |||||||||
| Address1: | 2122 HEALTH DR SW | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495199698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162525950 | ||||||||
| FaxNumber: | 6162525956 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 12/05/2017 | ||||||||
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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 | 207RC0000X | 5101014388 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 5101014388 | 01 | MI | STATE LICENSE | OTHER | P00245050 | 01 | MI | RAILROAD MEDICARE | OTHER | MS014388 | 01 | MI | BCBSM PIN | OTHER | 4729758 | 05 | MI | MEDICAID |