1366971152 NPI number — DR. MADHU MATHEW MD

Table of content: DR. MADHU MATHEW MD (NPI 1366971152)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366971152 NPI number — DR. MADHU MATHEW MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATHEW
Provider First Name:
MADHU
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VENNIKANDAM
Provider Other First Name:
MADHU
Provider Other Middle Name:
MATHEW
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1366971152
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1215 E MICHIGAN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48912-1811
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-364-3522
Provider Business Mailing Address Fax Number:
517-364-2763

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 N WINFIELD RD STE 420
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60190-1379
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-682-8700
Provider Business Practice Location Address Fax Number:
630-352-5582
Provider Enumeration Date:
06/06/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  4301503970 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RT0003X , with the licence number: 306030 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0008X , with the licence number: 306030 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 036161943 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)