Provider Demographics
NPI:1437155363
Name:AMBROSE, JAYASEELAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JAYASEELAN
Middle Name:
Last Name:AMBROSE
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 1:145 HOSPITAL AVE
Mailing Address - Street 2:STE 113
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1463
Mailing Address - Country:US
Mailing Address - Phone:814-375-3722
Mailing Address - Fax:814-375-3363
Practice Address - Street 1:145 HOSPITAL AVE
Practice Address - Street 2:STE 113
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1463
Practice Address - Country:US
Practice Address - Phone:814-375-3722
Practice Address - Fax:814-375-3363
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD061321L207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01757982Medicaid
PA950816Medicare ID - Type Unspecified
PA01757982Medicaid