Provider Demographics
NPI:1457683328
Name:GINCY KANDANKULAM
Entity Type:Organization
Organization Name:GINCY KANDANKULAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENN
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-755-2124
Mailing Address - Street 1:47 STATE ST
Mailing Address - Street 2:
Mailing Address - City:STRUTHERS
Mailing Address - State:OH
Mailing Address - Zip Code:44471-1939
Mailing Address - Country:US
Mailing Address - Phone:330-755-2124
Mailing Address - Fax:330-755-2276
Practice Address - Street 1:47 STATE ST
Practice Address - Street 2:
Practice Address - City:STRUTHERS
Practice Address - State:OH
Practice Address - Zip Code:44471-1939
Practice Address - Country:US
Practice Address - Phone:330-755-2124
Practice Address - Fax:330-755-2276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35094608207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty