Provider Demographics
NPI:1306038906
Name:MANNEM, RAJEEV REDDY (MD)
Entity Type:Individual
Prefix:DR
First Name:RAJEEV
Middle Name:REDDY
Last Name:MANNEM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DEPT OF RADIOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-3750
Mailing Address - Fax:414-805-3777
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DEPT OF RADIOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-3750
Practice Address - Fax:414-805-3777
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI520752085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1306038906Medicaid
WI736012670Medicare PIN