Basic Information
| Provider Information | |||||||||
| NPI: | 1861482473 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAJENDRAN | ||||||||
| FirstName: | MALLIKA | ||||||||
| MiddleName: | S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2357 SEQUOIA DR | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605066222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305857100 | ||||||||
| FaxNumber: | 6309073998 | ||||||||
| Practice Location | |||||||||
| Address1: | 2040 OGDEN AVE STE 401 | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605047208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305857100 | ||||||||
| FaxNumber: | 6309073969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 207V00000X | 036071407 | IL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 036071407 5 | 05 | IL | MEDICAID |