MEDICARE: SUSHILA M MATHEW MD

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	208000000X	Pediatrics Physician	022250	GA

General Provider Information

NPI Number	:	1770522534
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSHILA M MATHEW MD

Provider Business Mailing Address
First Line	:	193 NORTH PARK TRAIL
Second Line	:	STE 100
City	:	STOCKBRIDGE
State	:	GA
Zip	:	30281
Country	:	US
Telephone Number	:	770-389-0116
Fax Number	:	770-389-4058

Provider Business Practice Location Address
First Line	:	193 N PARK TRL
Second Line	:	STE 100
City	:	STOCKBRIDGE
State	:	GA
Zip	:	30281-7373
Country	:	US
Telephone Number	:	770-389-0116
Fax Number	:	770-389-4058

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

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	10/15/2011

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