Healthcare Provider Details

I. General information

NPI: 1417226721
Provider Name (Legal Business Name): RAMA K. KETHINENI MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2011
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

557 SANDHURST DR
FAYETTEVILLE NC
28304-4433
US

IV. Provider business mailing address

30 N 1900 E RM 4R312
SALT LAKE CITY UT
84132-0002
US

V. Phone/Fax

Practice location:
  • Phone: 910-484-8114
  • Fax: 910-223-0511
Mailing address:
  • Phone: 801-581-6709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number11729248-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number2023-02989
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35.125862
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01070789A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: