Provider Demographics
NPI:1730399379
Name:DR.AMITABH R. RAM MD LLC
Entity type:Organization
Organization Name:DR.AMITABH R. RAM MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LILA
Authorized Official - Middle Name:
Authorized Official - Last Name:EBRAHIMKHIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-228-9300
Mailing Address - Street 1:PO BOX 359
Mailing Address - Street 2:
Mailing Address - City:HEBRON
Mailing Address - State:CT
Mailing Address - Zip Code:06248-0359
Mailing Address - Country:US
Mailing Address - Phone:860-228-9300
Mailing Address - Fax:860-228-4703
Practice Address - Street 1:21 LIBERTY DR
Practice Address - Street 2:UNIT B
Practice Address - City:HEBRON
Practice Address - State:CT
Practice Address - Zip Code:06248-1553
Practice Address - Country:US
Practice Address - Phone:860-228-9300
Practice Address - Fax:860-228-4703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001349720Medicaid
CT004249802Medicaid
CT001349720Medicaid