MEDICARE: DR. POOVILLAM S SUBRAMANIAM-MOOTHATHU MD, FAAN, FAHA, CIME

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	2084N0400X	Neurology Physician	0101041206	VA

General Provider Information

NPI Number	:	1013910652
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. POOVILLAM S SUBRAMANIAM-MOOTHATHU MD, FAAN, FAHA, CIME

Provider Business Mailing Address
First Line	:	620 WALSING DR
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23229-8133
Country	:	US
Telephone Number	:	804-741-6484
Fax Number	:

Provider Business Practice Location Address
First Line	:	3400 BOULEVARD
Second Line	:
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-1418
Country	:	US
Telephone Number	:	804-741-6484
Fax Number	:

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

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	08/10/2011

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