Basic Information
| Provider Information | |||||||||
| NPI: | 1689985079 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | PULLALAREVU | ||||||||
| FirstName: | RAGHAVESH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 TOWN CENTER DR STE 203 | ||||||||
| Address2: | BEAUMONT MEDICAL STAFF AFFAIRS | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480841744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485858218 | ||||||||
| FaxNumber: | 2485858266 | ||||||||
| Practice Location | |||||||||
| Address1: | 3535 W 13 MILE RD STE 644 | ||||||||
| Address2: | BEAUMONT MULTI-ORGAN TRANSPLANT CLINIC | ||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480736770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002535592 | ||||||||
| FaxNumber: | 2485512125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2010 | ||||||||
| LastUpdateDate: | 06/23/2016 | ||||||||
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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 | 207R00000X | MT 198189 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | 4301110236 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.