Provider Demographics
NPI:1265478788
Name:RAM, MARUTHAVANAN (MD)
Entity Type:Individual
Prefix:
First Name:MARUTHAVANAN
Middle Name:
Last Name:RAM
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 1:26850 PROVIDENCE PKWY STE 455
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-1265
Mailing Address - Country:US
Mailing Address - Phone:248-465-4847
Mailing Address - Fax:
Practice Address - Street 1:26850 PROVIDENCE PKWY STE 455
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1265
Practice Address - Country:US
Practice Address - Phone:248-465-4847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301081482208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
7356181Medicare PIN