1629395868 NPI number — MRS. ANNAMMA JOHN MATHEW PMHNP

Table of content: MRS. ANNAMMA JOHN MATHEW PMHNP (NPI 1629395868)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629395868 NPI number — MRS. ANNAMMA JOHN MATHEW PMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATHEW
Provider First Name:
ANNAMMA
Provider Middle Name:
JOHN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PMHNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CHACKO
Provider Other First Name:
ANNAMMA
Provider Other Middle Name:
KOOTUMKAL
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629395868
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
JHS. HOSPITAL OF COOK COUNTY, 1901 W. HARRISON STREET
Provider Second Line Business Mailing Address:
DEPARTMENT OF PSYCHIATRY, ADMINISTRATION BUILDING
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60612-3714
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-864-8047
Provider Business Mailing Address Fax Number:
312-864-8014

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 W HARRISON ST
Provider Second Line Business Practice Location Address:
JHS. HOSPITAL OF COOK COUNTY, DEPARTMENT OF PSYCHIATRY
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612-3714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-864-8047
Provider Business Practice Location Address Fax Number:
312-864-8014
Provider Enumeration Date:
04/28/2010

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: 363LP0808X , with the licence number:  209.007801041.251125 , 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)





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