Provider Demographics
NPI:1770704058
Name:MATHAI, PREMILA (MD)
Entity type:Individual
Prefix:
First Name:PREMILA
Middle Name:
Last Name:MATHAI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PREMILA
Other - Middle Name:
Other - Last Name:KOSHI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3682 CINNAMON WAY
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-5700
Mailing Address - Country:US
Mailing Address - Phone:440-779-9148
Mailing Address - Fax:
Practice Address - Street 1:29000 CENTER RIDGE RD
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-5293
Practice Address - Country:US
Practice Address - Phone:440-835-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.066527207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0238451Medicaid
OH0238451Medicaid