Provider Demographics
NPI:1619008869
Name:SHANTHI RAJENDRAN PHYSICIAN PC
Entity Type:Organization
Organization Name:SHANTHI RAJENDRAN PHYSICIAN PC
Other - Org Name:AKRON FAMILY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANTHI
Authorized Official - Middle Name:
Authorized Official - Last Name:RAJENDRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-542-9300
Mailing Address - Street 1:187 VISCOUNT DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-1771
Mailing Address - Country:US
Mailing Address - Phone:716-689-4587
Mailing Address - Fax:
Practice Address - Street 1:16 MAIN ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:NY
Practice Address - Zip Code:14001-1220
Practice Address - Country:US
Practice Address - Phone:716-542-9300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211182207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAA0846Medicare ID - Type UnspecifiedMEDICARE