Basic Information
| Provider Information | |||||||||
| NPI: | 1356377915 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IMMARAJ | ||||||||
| FirstName: | PREMSWARUP | ||||||||
| MiddleName: | JOEL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PREMSWARUP | ||||||||
| OtherFirstName: | IMMARAJU | ||||||||
| OtherMiddleName: | JOEL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5447 EMBERWOOD WAY | ||||||||
| Address2: | |||||||||
| City: | SUGAR LAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774794273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8322644028 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 110 MEMORIAL HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773404940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9362913411 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 02/28/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | L4655 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | L4655 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 168572909 | 05 | TX | MEDICAID | 168572904 | 05 | TX | MEDICAID | 168572903 | 05 | TX | MEDICAID |