Provider Demographics
NPI:1740457902
Name:PANERU, RAM PRASAD (MD)
Entity type:Individual
Prefix:
First Name:RAM
Middle Name:PRASAD
Last Name:PANERU
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 1:123 4TH ST NW
Mailing Address - Street 2:
Mailing Address - City:BAGLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56621-8306
Mailing Address - Country:US
Mailing Address - Phone:218-694-6501
Mailing Address - Fax:218-694-6597
Practice Address - Street 1:123 4TH ST NW
Practice Address - Street 2:
Practice Address - City:BAGLEY
Practice Address - State:MN
Practice Address - Zip Code:56621-8306
Practice Address - Country:US
Practice Address - Phone:218-694-2384
Practice Address - Fax:218-694-6687
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND12193207Q00000X
MN51422207Q00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1740457902Medicaid
MNP01201779OtherRR MEDICARE
MNP01204945OtherRR MEDICARE
MNP01201785OtherRR MEDICARE
MN1740457902Medicaid
MN930004781Medicare UPIN
MN930004782Medicare UPIN