Provider Demographics
NPI:1770527012
Name:AMBALAVANAN, NAMASIVAYAM (MD)
Entity type:Individual
Prefix:
First Name:NAMASIVAYAM
Middle Name:
Last Name:AMBALAVANAN
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:PO BOX 55823
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35255-5823
Mailing Address - Country:US
Mailing Address - Phone:205-996-2244
Mailing Address - Fax:205-996-2254
Practice Address - Street 1:525 NHB
Practice Address - Street 2:619 SOUTH 19TH STREET
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35249-0001
Practice Address - Country:US
Practice Address - Phone:205-996-2244
Practice Address - Fax:205-996-2254
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL203622080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL00124464OtherMISSISSIPPI MEDICAID
AL4710057OtherUHC
AL47489OtherHEALTHSPRING
AL9940270Medicaid
AL51098585OtherBC BS
G21455OtherVIVA
AL9940270Medicaid
G21455OtherVIVA