Basic Information
| Provider Information | |||||||||
| NPI: | 1962485482 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TATA | ||||||||
| FirstName: | RAMACHANDRA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 255 HOSPITAL DR STE 208 | ||||||||
| Address2: | |||||||||
| City: | GLEN BURNIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210615801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105538160 | ||||||||
| FaxNumber: | 4105538159 | ||||||||
| Practice Location | |||||||||
| Address1: | 255 HOSPITAL DR STE 208 | ||||||||
| Address2: | |||||||||
| City: | GLEN BURNIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210615801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105538160 | ||||||||
| FaxNumber: | 4105538159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 03/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | D0092897 | MD | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 551704 | 01 | PA | BCBS PA | OTHER | 0016988180003 | 05 | PA | MEDICAID | 0016988180007 | 05 | PA | MEDICAID |