Healthcare Provider Details

I. General information

NPI: 1780766535
Provider Name (Legal Business Name): ANNAMMA MATHEW MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 05/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1158 W TAYLOR ST
CHICAGO IL
60607-4213
US

IV. Provider business mailing address

1158 W TAYLOR ST
CHICAGO IL
60607-4213
US

V. Phone/Fax

Practice location:
  • Phone: 312-455-8640
  • Fax: 312-455-2806
Mailing address:
  • Phone: 312-455-8640
  • Fax: 312-455-2806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-086152
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: