Provider Demographics
NPI:1750562898
Name:AMBI PHYSICIAN PC
Entity type:Organization
Organization Name:AMBI PHYSICIAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KANDASAMY
Authorized Official - Middle Name:
Authorized Official - Last Name:AMBALAVANAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-766-6447
Mailing Address - Street 1:PO BOX 1561
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21041-1561
Mailing Address - Country:US
Mailing Address - Phone:410-766-6447
Mailing Address - Fax:410-766-9780
Practice Address - Street 1:7485 OAKWOOD RD
Practice Address - Street 2:103
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061
Practice Address - Country:US
Practice Address - Phone:410-766-6447
Practice Address - Fax:410-766-9780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0051596261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD147400600Medicaid
MD147400600Medicaid
MD625MMedicare PIN