Provider Demographics
NPI:1972560522
Name:ANANDASIVAM, SUBRAMANIAM (MD PA)
Entity type:Individual
Prefix:
First Name:SUBRAMANIAM
Middle Name:
Last Name:ANANDASIVAM
Suffix:
Gender:M
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 S PRICE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78521-2459
Mailing Address - Country:US
Mailing Address - Phone:956-548-2242
Mailing Address - Fax:956-548-2262
Practice Address - Street 1:64 S PRICE RD
Practice Address - Street 2:SUITE A
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78521-2459
Practice Address - Country:US
Practice Address - Phone:956-548-2242
Practice Address - Fax:956-548-2262
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0605207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX030566601Medicaid
G33736Medicare UPIN
0053BEMedicare ID - Type Unspecified