Provider Demographics
NPI:1215590674
Name:GEORGE, RAJI
Entity Type:Individual
Prefix:
First Name:RAJI
Middle Name:
Last Name:GEORGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44509 WHITE PINE CIR W
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-4356
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4160 JOHN R ST STE 925
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2017
Practice Address - Country:US
Practice Address - Phone:313-745-7247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-20
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704252880163WM0705X, 363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner