=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215468483
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ABRAHAM MATHAI M.D., PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2017
-----------------------------------------------------
Last Update Date | 08/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1020 J L WHITE DR STE 170
-----------------------------------------------------
City | JASPER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30143-4910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-692-2437
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 RIVERSTONE VIS STE 206
-----------------------------------------------------
City | BLUE RIDGE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30513-6668
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-492-3200
-----------------------------------------------------
Fax | 706-492-3206
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 88913
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 88913
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------