Basic Information
| Provider Information | |||||||||
| NPI: | 1619941804 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MALISETTI | ||||||||
| FirstName: | RAJINI | ||||||||
| MiddleName: | KATIPAMULA | ||||||||
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| Credential: | MBBS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11850 BLACKFOOT NW | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637212100 | ||||||||
| FaxNumber: | 7637212190 | ||||||||
| Practice Location | |||||||||
| Address1: | 11850 BLACKFOOT NW | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637212100 | ||||||||
| FaxNumber: | 7637212190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 12/20/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 47014 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 115113400 | 05 | MN | MEDICAID |