Basic Information
| Provider Information | |||||||||
| NPI: | 1770700510 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATHEW | ||||||||
| FirstName: | ANIL | ||||||||
| MiddleName: | ABRAHAM | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 MCCLINTOCK DR STE 202 | ||||||||
| Address2: | |||||||||
| City: | BURR RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605270872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306556748 | ||||||||
| FaxNumber: | 5743350741 | ||||||||
| Practice Location | |||||||||
| Address1: | 13055 W MCDOWELL RD | ||||||||
| Address2: | |||||||||
| City: | AVONDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853926449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8822206432 | ||||||||
| FaxNumber: | 5743350779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2007 | ||||||||
| LastUpdateDate: | 09/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 238788 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | 01076796A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 201359350 | 05 | IN | MEDICAID |