Provider Demographics
NPI:1346222643
Name:AMBALAVANAN, SIVA (MD)
Entity Type:Individual
Prefix:
First Name:SIVA
Middle Name:
Last Name:AMBALAVANAN
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 1:500 LINCOLN PARK BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-6410
Mailing Address - Country:US
Mailing Address - Phone:937-222-3118
Mailing Address - Fax:937-222-1436
Practice Address - Street 1:500 LINCOLN PARK BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-6410
Practice Address - Country:US
Practice Address - Phone:937-222-3118
Practice Address - Fax:937-222-1436
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH74675207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
390005871OtherMEDICARE RAILROAD
D74675OtherHUMANA
2204490OtherAETNA
OH2102905Medicaid
000000035826OtherANTHEM
310821503030OtherCARE SOURCE
3108215037C16OtherUNITED MINE WORKERS
390005871OtherUHC
OH0853641Medicare ID - Type Unspecified
OH2102905Medicaid