Provider Demographics
NPI:1922061910
Name:AMBALAVANAN, SURIANARAYANAN (MD)
Entity Type:Individual
Prefix:
First Name:SURIANARAYANAN
Middle Name:
Last Name:AMBALAVANAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:200 SAINT CLAIR AVE
Mailing Address - Street 2:JTDM FAMILY PRACTICE LLC
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-2400
Mailing Address - Country:US
Mailing Address - Phone:419-394-3387
Mailing Address - Fax:419-586-8509
Practice Address - Street 1:801 PRO DR STE D4
Practice Address - Street 2:VANAN ENT & SINUS CENTER
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822-3307
Practice Address - Country:US
Practice Address - Phone:419-586-6480
Practice Address - Fax:419-586-8509
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35-090880207Y00000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2820755Medicaid
OH1184652539OtherGROUP NPI
OH9934723OtherMEDICARE GROUP PTAN
OH2820755Medicaid
KY9720Medicare PIN
KY000000219680OtherANTHEM BLUE CROSS
WV0351000000OtherWVA MEDICAID PIN
OH2820755Medicaid
KY040017615OtherPALMETTO GBA
WV3810002865OtherWV MEDICAID GROUP
OH4230662Medicare PIN