Provider Demographics
NPI:1063426922
Name:RAMANATHAN, JAMBUNATHAN (MD)
Entity type:Individual
Prefix:
First Name:JAMBUNATHAN
Middle Name:
Last Name:RAMANATHAN
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 1:1183 BRADBURY DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-6314
Mailing Address - Country:US
Mailing Address - Phone:248-267-6558
Mailing Address - Fax:248-267-6558
Practice Address - Street 1:4646 JOHN R
Practice Address - Street 2:JOHN.D.DINGELL VA
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-576-1000
Practice Address - Fax:313-576-1000
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063102207RI0200X, 207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4726068Medicaid
R67353Medicare UPIN