Provider Demographics
NPI:1437125986
Name:GANABATHI, KUMARESAN (MD)
Entity Type:Individual
Prefix:
First Name:KUMARESAN
Middle Name:
Last Name:GANABATHI
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 1:100 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1440
Mailing Address - Country:US
Mailing Address - Phone:814-849-8858
Mailing Address - Fax:
Practice Address - Street 1:240 ALLEGHENY BLVD
Practice Address - Street 2:SUITE J
Practice Address - City:BROOKVILLE
Practice Address - State:PA
Practice Address - Zip Code:15825-2323
Practice Address - Country:US
Practice Address - Phone:814-849-8858
Practice Address - Fax:814-849-3741
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD053586L208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAF95305Medicare UPIN
PA575946Medicare PIN