Provider Demographics
NPI:1568519379
Name:RUDRARAJU, SUDHA (MD)
Entity Type:Individual
Prefix:
First Name:SUDHA
Middle Name:
Last Name:RUDRARAJU
Suffix:
Gender:F
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:HENRY FORD HEALTH SYSTEM
Mailing Address - Street 2:24565 HAIG ROAD
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180
Mailing Address - Country:US
Mailing Address - Phone:313-375-2000
Mailing Address - Fax:
Practice Address - Street 1:HENRY FORD HEALTH SYSTEM
Practice Address - Street 2:24565 HAIG ROAD
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180
Practice Address - Country:US
Practice Address - Phone:313-375-2000
Practice Address - Fax:313-375-2235
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301062364208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SR062364OtherCHAMPUS-CHAMPUS
MI327180210Medicaid
SR062364OtherCOMMERCIAL-COMMERCIAL NUMBER
700H262280OtherBLUE CROSS-BLUE CROSS
SR062364OtherCOMMERCIAL-COMMERCIAL NUMBER
SR062364OtherCHAMPUS-CHAMPUS