Provider Demographics
NPI:1477527380
Name:SUBBANNA JAYAPRAKASH, M.D., S.C.
Entity Type:Organization
Organization Name:SUBBANNA JAYAPRAKASH, M.D., S.C.
Other - Org Name:REHABILITATION PHYSICIANS OF RACINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUBBANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:JAYAPRAKASH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-598-1001
Mailing Address - Street 1:6015 DURAND AVE
Mailing Address - Street 2:500
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-5089
Mailing Address - Country:US
Mailing Address - Phone:262-598-1001
Mailing Address - Fax:
Practice Address - Street 1:6015 DURAND AVE
Practice Address - Street 2:500
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-5089
Practice Address - Country:US
Practice Address - Phone:262-598-1001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27676208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32783300Medicaid
WI31477200Medicaid
WI32783300Medicaid
WI52320Medicare ID - Type Unspecified