Provider Demographics
NPI:1013217603
Name:RAVIKUMAR KANNEGANTI MD PA
Entity Type:Organization
Organization Name:RAVIKUMAR KANNEGANTI MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RAVIKUMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:KANNEGANTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-813-1765
Mailing Address - Street 1:PO BOX 21313
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77720-1313
Mailing Address - Country:US
Mailing Address - Phone:409-813-1765
Mailing Address - Fax:409-813-1875
Practice Address - Street 1:3250 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-4627
Practice Address - Country:US
Practice Address - Phone:409-813-1765
Practice Address - Fax:409-813-1875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-28
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6867174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114668001Medicaid
TXE57427Medicare UPIN