Provider Demographics
NPI:1114944006
Name:PANNEERSELVAM, USHA (MD)
Entity Type:Individual
Prefix:DR
First Name:USHA
Middle Name:
Last Name:PANNEERSELVAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 SAGAMORE RD
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-4600
Mailing Address - Country:US
Mailing Address - Phone:401-946-0656
Mailing Address - Fax:
Practice Address - Street 1:351 BUDLONG RD
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-6001
Practice Address - Country:US
Practice Address - Phone:401-943-1860
Practice Address - Fax:401-943-8952
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI10133207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9020788Medicaid
RIH02004Medicare UPIN
RI119020788Medicare ID - Type Unspecified