Basic Information
| Provider Information | |||||||||
| NPI: | 1578659793 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAJESWAREN | ||||||||
| FirstName: | RAJ | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6002 | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618036002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173268630 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2300 N VERMILION AVENUE | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618321735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174317830 | ||||||||
| FaxNumber: | 2174317756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 12/09/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 036062517 | IL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 036062517 | 05 | IL | MEDICAID |