Provider Demographics
NPI:1114556826
Name:MATHEW, TRICIA GRACE (MD)
Entity Type:Individual
Prefix:DR
First Name:TRICIA
Middle Name:GRACE
Last Name:MATHEW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 W WELLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5147
Mailing Address - Country:US
Mailing Address - Phone:773-561-7500
Mailing Address - Fax:
Practice Address - Street 1:4600 N RAVENSWOOD AVE FL 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4510
Practice Address - Country:US
Practice Address - Phone:773-561-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-04
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.076116207Q00000X
390200000X
IL036-166646207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program