Provider Demographics
NPI:1710019955
Name:GUNABALAN, RAM (MD)
Entity Type:Individual
Prefix:DR
First Name:RAM
Middle Name:
Last Name:GUNABALAN
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 1:30781 STEPHENSON HWY
Mailing Address - Street 2:
Mailing Address - City:MADISON HTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-1618
Mailing Address - Country:US
Mailing Address - Phone:248-583-8922
Mailing Address - Fax:248-583-8969
Practice Address - Street 1:363 W BIG BEAVER RD
Practice Address - Street 2:SUITE 200
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-5220
Practice Address - Country:US
Practice Address - Phone:248-619-9771
Practice Address - Fax:248-583-8969
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032784207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MILICENSE NUMBEROther4301032784
MIBCBSM PIN NUMBEROther0827216
MILICENSE NUMBEROther4301032784