Provider Demographics
NPI:1861549941
Name:PUNNAMMA MEMORIAL REHAB CLINIC
Entity type:Organization
Organization Name:PUNNAMMA MEMORIAL REHAB CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:SANDYA
Authorized Official - Middle Name:RANI
Authorized Official - Last Name:KALAPALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-485-7500
Mailing Address - Street 1:2323 MURDOCH AVE
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-2532
Mailing Address - Country:US
Mailing Address - Phone:304-485-7500
Mailing Address - Fax:304-485-6777
Practice Address - Street 1:1504 GRAND CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-1058
Practice Address - Country:US
Practice Address - Phone:304-485-7500
Practice Address - Fax:304-485-6777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20619207R00000X
WV21321207R00000X
WV17059208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0078260000Medicaid
WV0203567000Medicaid
WVF41016Medicare UPIN
WV0203567000Medicaid