MEDICARE: MRS. JATHA JOHN MATHEW NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208M00000X	Hospitalist Physician	22785	SC
2	363LF0000X	Family Nurse Practitioner	22785	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184285496
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JATHA JOHN MATHEW NP

Provider Business Mailing Address
First Line	:	300 E MCBEE AVE FL 4
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29601-2842
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	701 GROVE RD FL 5
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29605-4295
Country	:	US
Telephone Number	:	864-455-4411
Fax Number	:	864-455-4480

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2019
Last Update Date	:	07/28/2021

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