Basic Information
Provider Information | |||||||||
NPI: | 1639481914 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOVINDARAJAN | ||||||||
FirstName: | RAGHAV | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3 SAINT ELIZABETH BLVD | ||||||||
Address2: |   | ||||||||
City: | O FALLON | ||||||||
State: | IL | ||||||||
PostalCode: | 622691281 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6186415803 | ||||||||
FaxNumber: | 6186075116 | ||||||||
Practice Location | |||||||||
Address1: | 3 SAINT ELIZABETH BLVD | ||||||||
Address2: |   | ||||||||
City: | O FALLON | ||||||||
State: | IL | ||||||||
PostalCode: | 622691281 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6186415803 | ||||||||
FaxNumber: | 6186075116 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/02/2010 | ||||||||
LastUpdateDate: | 12/28/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/28/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 2013017438 | MO | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0008X | 2013017438 | MO | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neuromuscular Medicine |
No ID Information.