=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629581749
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAIKUMAR RAVUNNIARATH MEDICAL P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2017
-----------------------------------------------------
Last Update Date | 11/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | NEW PALTZ CENTER FOR REHAB AND NURSING 1 JANSEN ROAD
-----------------------------------------------------
City | NEW PALTZ
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12561-3811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-255-0830
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 38 WILDWOOD DR
-----------------------------------------------------
City | POUGHKEEPSIE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12603-5828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-594-8895
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JAIKUMAR RAVUNNIARATH MENON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 845-594-8895
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 251537
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------