Provider Demographics
NPI:1548314495
Name:MATTHEW MACK ABRAHAM, LLC
Entity type:Organization
Organization Name:MATTHEW MACK ABRAHAM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:MACK
Authorized Official - Last Name:ABRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-289-5605
Mailing Address - Street 1:100 ASMA BLVD
Mailing Address - Street 2:BLDG ONE, STE 205
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3858
Mailing Address - Country:US
Mailing Address - Phone:337-289-5605
Mailing Address - Fax:337-289-5609
Practice Address - Street 1:100 ASMA BLVD
Practice Address - Street 2:BLDG ONE, STE 205
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-3858
Practice Address - Country:US
Practice Address - Phone:337-289-5605
Practice Address - Fax:337-289-5609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD024082207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CT14Medicare ID - Type Unspecified
LAH21801Medicare UPIN