1710019955 NPI number — DR. RAM GUNABALAN MD

Table of content: DR. RAM GUNABALAN MD (NPI 1710019955)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710019955 NPI number — DR. RAM GUNABALAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUNABALAN
Provider First Name:
RAM
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710019955
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30781 STEPHENSON HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON HTS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48071-1618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-583-8922
Provider Business Mailing Address Fax Number:
248-583-8969

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
363 W BIG BEAVER RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48084-5220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-619-9771
Provider Business Practice Location Address Fax Number:
248-583-8969
Provider Enumeration Date:
03/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  4301032784 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: LICENSE NUMBER . This is a "4301032784" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: BCBSM PIN NUMBER . This is a "0827216" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com