Basic Information
| Provider Information | |||||||||
| NPI: | 1003806738 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAMAKRISHNAN | ||||||||
| FirstName: | MANNACHANALLUR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1745 VALLEY VIEW DR E | ||||||||
| Address2: | |||||||||
| City: | BIG STONE GAP | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242193313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2765237943 | ||||||||
| FaxNumber: | 2765237028 | ||||||||
| Practice Location | |||||||||
| Address1: | 9480 HIGHWAY 805 | ||||||||
| Address2: | |||||||||
| City: | JENKINS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 415378182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2765237943 | ||||||||
| FaxNumber: | 2765237028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2005 | ||||||||
| LastUpdateDate: | 12/26/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 0101030628 | VA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 64662257 | 05 | KY | MEDICAID | 007213913 | 05 | VA | MEDICAID |