Basic Information
| Provider Information | |||||||||
| NPI: | 1891802823 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATHEW | ||||||||
| FirstName: | RAICHAL | ||||||||
| MiddleName: | T. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 LAKESIDE AVE E | ||||||||
| Address2: | #1200 | ||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441141158 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 10 SEVERANCE CIR | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441181533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165247377 | ||||||||
| FaxNumber: | 2162972562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 10/09/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35-051002 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0591060 | 05 | OH | MEDICAID |