Basic Information
| Provider Information | |||||||||
| NPI: | 1861549941 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PUNNAMMA MEMORIAL REHAB CLINIC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PMR CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2323 MURDOCH AVE | ||||||||
| Address2: | |||||||||
| City: | PARKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261012532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044857500 | ||||||||
| FaxNumber: | 3044856777 | ||||||||
| Practice Location | |||||||||
| Address1: | 1504 GRAND CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261051058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044857500 | ||||||||
| FaxNumber: | 3044856777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 02/21/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KALAPALA | ||||||||
| AuthorizedOfficialFirstName: | SANDYA | ||||||||
| AuthorizedOfficialMiddleName: | RANI | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3044857500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 20619 | WV | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 21321 | WV | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208100000X | 17059 | WV | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 0078260000 | 05 | WV | MEDICAID | 0203567000 | 05 | WV | MEDICAID |