Provider Demographics
NPI:1376583658
Name:ABRAHAM, MARIETTA P (MD)
Entity Type:Individual
Prefix:
First Name:MARIETTA
Middle Name:P
Last Name:ABRAHAM
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 1:13707 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-3188
Mailing Address - Country:US
Mailing Address - Phone:815-337-1871
Mailing Address - Fax:815-338-6297
Practice Address - Street 1:10350 HALIGUS RD
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142-9545
Practice Address - Country:US
Practice Address - Phone:815-338-6600
Practice Address - Fax:847-802-7162
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036109708207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04532206OtherBLUE CROSS BLUE SHIELD
ILK49671Medicare PIN
IL04532206OtherBLUE CROSS BLUE SHIELD
ILK08882Medicare UPIN
ILK49670Medicare PIN