Basic Information
| Provider Information | |||||||||
| NPI: | 1376532556 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAJ | ||||||||
| FirstName: | ETHIRAJ | ||||||||
| MiddleName: | GOVINDA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1165 S LINDEN RD | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107325400 | ||||||||
| FaxNumber: | 8107331624 | ||||||||
| Practice Location | |||||||||
| Address1: | 1165 S LINDEN RD | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107325400 | ||||||||
| FaxNumber: | 8107331624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 09/29/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 4301039365 | MI | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1100482 | 01 | MI | HEALTH PLUS OF MICHIGAN | OTHER | ER039365 | 01 | MI | STATE LICENSE NUMBER | OTHER | 0B51240, ER039365 | 01 | MI | BLUE CARE NETWORK | OTHER | C1855 | 01 | MI | MCARE | OTHER | 1010892 | 01 | MI | MCLAREN HEALTH PLAN | OTHER | 0B51240 | 01 | MI | BLUE CROSS BLUE SHIELD MI | OTHER | 1010892 | 01 | MI | MCLAREN HEALTH ADVANTAGE | OTHER | 4591753 | 05 | MI | MEDICAID |