Provider Demographics
NPI:1023255858
Name:KADALIKATTIL THOMAS, MATHEW (MD)
Entity type:Individual
Prefix:DR
First Name:MATHEW
Middle Name:
Last Name:KADALIKATTIL THOMAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1162 ADAMSVILLE RD N
Mailing Address - Street 2:
Mailing Address - City:MC COLL
Mailing Address - State:SC
Mailing Address - Zip Code:29570-5001
Mailing Address - Country:US
Mailing Address - Phone:716-239-6879
Mailing Address - Fax:
Practice Address - Street 1:1138 CHERAW ST
Practice Address - Street 2:
Practice Address - City:BENNETTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29512-2466
Practice Address - Country:US
Practice Address - Phone:843-454-8580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-15
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC31752207P00000X, 207PE0004X
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI317525Medicaid
RI317525Medicaid