Basic Information
| Provider Information | |||||||||
| NPI: | 1659508687 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIVARAJU | ||||||||
| FirstName: | KANNAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 ROUTE 46 E STE 450 | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070041583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9735593700 | ||||||||
| FaxNumber: | 9735598650 | ||||||||
| Practice Location | |||||||||
| Address1: | 271 GROVE AVE | ||||||||
| Address2: | |||||||||
| City: | VERONA | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070441730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9732392600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2009 | ||||||||
| LastUpdateDate: | 12/30/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/30/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 25MA08777500 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
No ID Information.