Provider Demographics
NPI:1356652762
Name:ANANTH SHANMUGAM MD INC
Entity Type:Organization
Organization Name:ANANTH SHANMUGAM MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:POORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-452-6682
Mailing Address - Street 1:8001 BRUCEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-2329
Mailing Address - Country:US
Mailing Address - Phone:916-452-6682
Mailing Address - Fax:916-452-6683
Practice Address - Street 1:8001 BRUCEVILLE RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2329
Practice Address - Country:US
Practice Address - Phone:916-452-6682
Practice Address - Fax:916-452-6683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-30
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA905792084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A905790OtherMEDICARE PTAN