Healthcare Provider Details

I. General information

NPI: 1881671204
Provider Name (Legal Business Name): JAYANTHI RAVISANKAR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 02/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 LEGACY DR
BEREA KY
40403-9594
US

IV. Provider business mailing address

1010 MAIN ST S
MC KEE KY
40447-7089
US

V. Phone/Fax

Practice location:
  • Phone: 859-986-2323
  • Fax: 859-986-7728
Mailing address:
  • Phone: 606-287-7104
  • Fax: 606-287-4409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34558
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: