Provider Demographics
NPI:1114945144
Name:KOSARAJU, RADHIKA (MD)
Entity Type:Individual
Prefix:
First Name:RADHIKA
Middle Name:
Last Name:KOSARAJU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MINERAL POINT AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-2940
Mailing Address - Country:US
Mailing Address - Phone:608-756-6000
Mailing Address - Fax:608-756-6236
Practice Address - Street 1:1404 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2335
Practice Address - Country:US
Practice Address - Phone:815-967-5476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI53725-020207R00000X, 208M00000X
MI5301083282207R00000X
IL036118570207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110B561250OtherCOMMUNITY BLUE
MI110B561250OtherBLUE CARE NETWORK
MICA5169 P00357911OtherMETRAHEALTH
MI110B561250OtherBLUECROSS BLUE SHIELD OF
MI01003173OtherGENESEE HEALTH PLAN
MI1020379OtherMHP HAN
MI17573OtherMCARE
MI01003173OtherHEALTH PLUS
IL036118570-5Medicaid
MI110B561250OtherBLUE CHOICE
MI4855305Medicaid
ILIL7492070Medicare PIN
MI01003173OtherGENESEE HEALTH PLAN
MI110B561250OtherCOMMUNITY BLUE
MI4855305Medicaid