Healthcare Provider Details

I. General information

NPI: 1669038097
Provider Name (Legal Business Name): RENY MARY MATHEW MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2019
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE # 1223
EVANSTON IL
60201-1700
US

IV. Provider business mailing address

2650 RIDGE AVE # 1223
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 847-982-3172
  • Fax: 847-733-5108
Mailing address:
  • Phone: 478-982-3172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036161744
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: