Basic Information
| Provider Information | |||||||||
| NPI: | 1396731865 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUNDARAM | ||||||||
| FirstName: | RAJENDRAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5334 MEADOW LANE CT | ||||||||
| Address2: | |||||||||
| City: | SHEFFIELD VILLAGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440351469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409345454 | ||||||||
| FaxNumber: | 4409348999 | ||||||||
| Practice Location | |||||||||
| Address1: | 5172 LEAVITT RD | ||||||||
| Address2: | |||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440532384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402827420 | ||||||||
| FaxNumber: | 4402829855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 11/14/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35072485 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110185582 | 01 | OH | RR MEDICARE | OTHER | 2023367 | 05 | OH | MEDICAID |