Provider Demographics
NPI:1366450678
Name:RAJAGURU, SUBBIAH (MD)
Entity Type:Individual
Prefix:DR
First Name:SUBBIAH
Middle Name:
Last Name:RAJAGURU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3909
Mailing Address - Country:US
Mailing Address - Phone:217-366-1304
Mailing Address - Fax:
Practice Address - Street 1:101 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3909
Practice Address - Country:US
Practice Address - Phone:217-366-1304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-089144207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
110120109OtherRAILROAD MEDICARE
IL036089144 1Medicaid
279500OtherMEDICARE GROUP
ILF96080Medicare UPIN
IL0407950001Medicare NSC
279500OtherMEDICARE GROUP