Provider Demographics
NPI:1659302453
Name:RAINA, SURESH (MD)
Entity Type:Individual
Prefix:
First Name:SURESH
Middle Name:
Last Name:RAINA
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 1:30 BERGEN ST
Mailing Address - Street 2:ADMC 12 1205
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-3000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 BERGEN ST
Practice Address - Street 2:ADMC 12 1205
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-3000
Practice Address - Country:US
Practice Address - Phone:973-972-0037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03063700208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1261304Medicaid
NJ1261304Medicaid
NJ538913Medicare ID - Type Unspecified