Healthcare Provider Details

I. General information

NPI: 1063459592
Provider Name (Legal Business Name): ANANTHASEKAR PONNAMBALAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 03/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 CENTER STREET SUITE 1S
MOBILE AL
36604-3207
US

IV. Provider business mailing address

PO BOX 40480
MOBILE AL
36640-0480
US

V. Phone/Fax

Practice location:
  • Phone: 251-410-5437
  • Fax: 251-434-3852
Mailing address:
  • Phone: 251-410-5437
  • Fax: 251-434-3852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberMD424450
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number28395
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: