Provider Demographics
NPI:1639450489
Name:MATHISON, MARTHA (MED)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:
Last Name:MATHISON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:MRS
Other - First Name:BETH
Other - Middle Name:
Other - Last Name:MATHISON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MED
Mailing Address - Street 1:234 PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-4052
Mailing Address - Country:US
Mailing Address - Phone:770-382-1879
Mailing Address - Fax:770-382-2601
Practice Address - Street 1:1955 LAKE PARK DR SE STE 300
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-8855
Practice Address - Country:US
Practice Address - Phone:770-514-2462
Practice Address - Fax:770-514-2803
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator