Provider Demographics
NPI:1669611596
Name:SUBRA ANANDASIVAM MD PA
Entity type:Organization
Organization Name:SUBRA ANANDASIVAM MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:SUBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANANDASIVAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-548-2242
Mailing Address - Street 1:64 S PRICE RD
Mailing Address - Street 2:STE A
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78521-2459
Mailing Address - Country:US
Mailing Address - Phone:956-548-2242
Mailing Address - Fax:956-548-2262
Practice Address - Street 1:64 S PRICE RD
Practice Address - Street 2:STE A
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78521-2459
Practice Address - Country:US
Practice Address - Phone:956-548-2242
Practice Address - Fax:956-548-2262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-17
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5222207R00000X
TXK0605207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX030566601Medicaid
TX156202701Medicaid