Provider Demographics
NPI:1093926552
Name:KADARNATH S BOODRAM MD LLC
Entity type:Organization
Organization Name:KADARNATH S BOODRAM MD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:BOODRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-526-7900
Mailing Address - Street 1:4300 CROSSINGS BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:PRINCE GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23875-1452
Mailing Address - Country:US
Mailing Address - Phone:804-526-7900
Mailing Address - Fax:804-526-7195
Practice Address - Street 1:4300 CROSSINGS BLVD STE 101
Practice Address - Street 2:
Practice Address - City:PRINCE GEORGE
Practice Address - State:VA
Practice Address - Zip Code:23875-1452
Practice Address - Country:US
Practice Address - Phone:804-526-7900
Practice Address - Fax:804-526-7195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2024-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101229800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0408689OtherUNITED HEALTHCARE
VA7604973OtherGHI
VA010124701Medicaid
VI8130003OtherMAMSI
VI0504963OtherCIGNA
VI254668OtherSOUOTHERN HEALTH
VA3689195OtherAETNA HMO
VI54180OtherCARENET
VA172714OtherANTHEM
VA7404178OtherAETNA PPO
VA94167OtherSENTARA OPTIMA
VA010124701Medicaid
VA94167OtherSENTARA OPTIMA
VI0504963OtherCIGNA