Healthcare Provider Details

I. General information

NPI: 1669043063
Provider Name (Legal Business Name): SRUTHI PRIYAVADHANA RAMANAN MBBS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2021
Last Update Date: 11/23/2022
Certification Date: 11/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE, JACKSON
JACKSON MI
49201
US

IV. Provider business mailing address

205 N EAST AVE, JACKSON
JACKSON MI
49201
US

V. Phone/Fax

Practice location:
  • Phone: 517-936-1104
  • Fax:
Mailing address:
  • Phone: 517-936-1104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: