Provider Demographics
NPI:1508839937
Name:RAMAMRUTHAM, RADHA A (MD)
Entity Type:Individual
Prefix:
First Name:RADHA
Middle Name:A
Last Name:RAMAMRUTHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 W BLUE SKY DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-5333
Mailing Address - Country:US
Mailing Address - Phone:623-434-0152
Mailing Address - Fax:623-583-1099
Practice Address - Street 1:20325 N 51ST AVE BLDG 6
Practice Address - Street 2:SUITE 142
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-5674
Practice Address - Country:US
Practice Address - Phone:623-587-4500
Practice Address - Fax:623-587-4681
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27554207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ143142Medicare PIN
AZ74315Medicare ID - Type UnspecifiedMEDICARE
AZH81775Medicare UPIN