Basic Information
| Provider Information | |||||||||
| NPI: | 1265669683 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAYRAM | ||||||||
| FirstName: | GAUTAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 409879 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152616000 | ||||||||
| FaxNumber: | 6152616052 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 CHARLOTTE AVE | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152509200 | ||||||||
| FaxNumber: | 6152509251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2009 | ||||||||
| LastUpdateDate: | 08/07/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | D74312 | MD | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 125-051491 | IL | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 51217 | TN | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 55171600 | 05 | MD | MEDICAID |