Provider Demographics
NPI:1386854792
Name:RAJ, PREM (RPT)
Entity Type:Individual
Prefix:
First Name:PREM
Middle Name:
Last Name:RAJ
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 71772
Mailing Address - Street 2:
Mailing Address - City:MADISON HTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071
Mailing Address - Country:US
Mailing Address - Phone:313-926-2529
Mailing Address - Fax:
Practice Address - Street 1:11509 SAINT AUBIN ST
Practice Address - Street 2:
Practice Address - City:HAMTRAMCK
Practice Address - State:MI
Practice Address - Zip Code:48212
Practice Address - Country:US
Practice Address - Phone:313-926-2529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005931174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP14120Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE PROVI