MEDICARE: MATTHEW MACK ABRAHAM, LLC

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	207RS0012X	Sleep Medicine (Internal Medicine) Physician	MD024082	LA

General Provider Information

NPI Number	:	1548314495
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MATTHEW MACK ABRAHAM, LLC

Provider Business Mailing Address
First Line	:	100 ASMA BLVD
Second Line	:	BLDG ONE, STE 205
City	:	LAFAYETTE
State	:	LA
Zip	:	70508-3858
Country	:	US
Telephone Number	:	337-289-5605
Fax Number	:	337-289-5609

Provider Business Practice Location Address
First Line	:	100 ASMA BLVD
Second Line	:	BLDG ONE, STE 205
City	:	LAFAYETTE
State	:	LA
Zip	:	70508-3858
Country	:	US
Telephone Number	:	337-289-5605
Fax Number	:	337-289-5609

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MATTHEW MACK ABRAHAM
Credential	:	M.D.
Telephone Number	:	337-289-5605

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	08/22/2020

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