MEDICARE: ANANDARAJ SUBRAMANIUM M.D.

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	207Q00000X	Family Medicine Physician	E-4624	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	E-4624	OTHER	AR	LICENSE

General Provider Information

NPI Number	:	1194767657
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANANDARAJ SUBRAMANIUM M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1198
Second Line	:
City	:	MOUNTAIN VIEW
State	:	AR
Zip	:	72560-1198
Country	:	US
Telephone Number	:	870-269-7777
Fax Number	:	870-269-5055

Provider Business Practice Location Address
First Line	:	1809 OZARKA COLLEGE DRIVE
Second Line	:
City	:	MOUNTAIN VIEW
State	:	AR
Zip	:	72560-1198
Country	:	US
Telephone Number	:	870-269-7777
Fax Number	:	870-269-5055

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

Provider Enumeration Date	:	06/11/2006
Last Update Date	:	12/17/2013

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