Basic Information
Provider Information | |||||||||
NPI: | 1356303093 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RAIJI | ||||||||
FirstName: | TUSHAR | ||||||||
MiddleName: | N. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 44047 | ||||||||
Address2: |   | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482440047 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8107205715 | ||||||||
FaxNumber: | 8107320891 | ||||||||
Practice Location | |||||||||
Address1: | 6203 COVERED WAGONS TRL | ||||||||
Address2: |   | ||||||||
City: | FLINT | ||||||||
State: | MI | ||||||||
PostalCode: | 485322170 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8107320288 | ||||||||
FaxNumber: | 8107320891 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/06/2006 | ||||||||
LastUpdateDate: | 01/15/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301035669 | MI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1102557582 | 01 | MI | HEALTHPLUS | OTHER | 1102514291 | 01 | MI | BCBSM/BCN | OTHER | 110B56125 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 110B510530 | 01 | MI | COMMUNITY BLUE | OTHER | A76953 | 01 | MI | HAP | OTHER | C1896 | 01 | MI | MCARE | OTHER | 4289801 | 05 | MI |   | MEDICAID | 110B510530 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 110B510530 | 01 | MI | BLUE CHOICE | OTHER | 110B510530 | 01 | MI | BLUE CARE NETWORK | OTHER | A76953 | 01 | MI | HEALTH NET FEDRAL SERVIC | OTHER |