Basic Information
| Provider Information | |||||||||
| NPI: | 1144269432 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEVESHWAR | ||||||||
| FirstName: | RAJEEV | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MICHIGAN ST NE | ||||||||
| Address2: | MC845 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164866790 | ||||||||
| FaxNumber: | 6164866702 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 MICHIGAN ST NE STE 6100 | ||||||||
| Address2: | SPECTRUM HEALTH MEDICAL GROUP NEUROVASCULAR/STROKE OFFI | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162677900 | ||||||||
| FaxNumber: | 6162677901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 12/08/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 036100789 | IL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2085R0202X | 036100789 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 036100789 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2084V0102X | 4301053380 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Vascular Neurology | 2085R0204X | 4301053380 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | 4301053380 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | CA4748 | 01 | MEDICARE RAILROAD (GROUP) | OTHER | 206147 | 01 | MEDICARE PTAN (GROUP) | OTHER | P00904920 | 01 | MEDICARE RAILROAD (INDIVIDUAL) | OTHER | 206147039 | 01 | MEDICARE PTAN (INDIVIDUAL) | OTHER |