MEDICARE: PANCHARATHNA K ATHMARAM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	35051805	OH

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	110188865	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164416210
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PANCHARATHNA K ATHMARAM MD

Provider Business Mailing Address
First Line	:	661 PARK AVE E
Second Line	:	SUITE A
City	:	MANSFIELD
State	:	OH
Zip	:	44905-2880
Country	:	US
Telephone Number	:	419-526-3999
Fax Number	:	419-526-1137

Provider Business Practice Location Address
First Line	:	661 PARK AVE E
Second Line	:	SUITE A
City	:	MANSFIELD
State	:	OH
Zip	:	44905-2880
Country	:	US
Telephone Number	:	419-526-3999
Fax Number	:	419-526-1137

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/06/2005
Last Update Date	:	10/21/2009

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