MEDICARE: KALYAN KUMAR RATH M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR1300X	Rural Health Clinic/Center	K1016	TX
2	208000000X	Pediatrics Physician	K1016	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639188147
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KALYAN KUMAR RATH M.D.

Provider Business Mailing Address
First Line	:	1273 S. PEACHTREE ST.
Second Line	:
City	:	JASPER
State	:	TX
Zip	:	75951
Country	:	US
Telephone Number	:	409-384-9200
Fax Number	:	409-384-9205

Provider Business Practice Location Address
First Line	:	1273 S PEACHTREE
Second Line	:
City	:	JASPER
State	:	TX
Zip	:	75951
Country	:	US
Telephone Number	:	409-384-9200
Fax Number	:	409-384-9205

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	06/01/2011

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