Basic Information
| Provider Information | |||||||||
| NPI: | 1568723211 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAJU | ||||||||
| FirstName: | PRADEEP | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | BOX 78534 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153989491 | ||||||||
| FaxNumber: | 8153817498 | ||||||||
| Practice Location | |||||||||
| Address1: | 4119 W SHAMROCK LN | ||||||||
| Address2: | |||||||||
| City: | MCHENRY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600508268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153989491 | ||||||||
| FaxNumber: | 8153817498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2012 | ||||||||
| LastUpdateDate: | 12/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036140194 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | 036140194 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0114301 | 05 | OH | MEDICAID | 036140194 | 05 | IL | MEDICAID |