Provider Demographics
NPI:1124538301
Name:RAJENDRAN, KAVITHA (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:KAVITHA
Middle Name:
Last Name:RAJENDRAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5851 W. 95TH STREET
Mailing Address - Street 2:SUITE 300
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453
Mailing Address - Country:US
Mailing Address - Phone:708-499-9980
Mailing Address - Fax:708-499-6203
Practice Address - Street 1:5851 W. 95TH STREET
Practice Address - Street 2:SUITE 300
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453
Practice Address - Country:US
Practice Address - Phone:708-499-9980
Practice Address - Fax:708-499-6203
Is Sole Proprietor?:No
Enumeration Date:2017-10-02
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.006373363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4111771OtherIDFPR