Provider Demographics
NPI:1255367231
Name:RAJU,, RAMESH PENUMETSA (MD)
Entity type:Individual
Prefix:
First Name:RAMESH
Middle Name:PENUMETSA
Last Name:RAJU,
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PENUMETSA
Other - Middle Name:RAMESH
Other - Last Name:RAJU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:255 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2218
Mailing Address - Country:US
Mailing Address - Phone:517-787-6440
Mailing Address - Fax:517-787-4146
Practice Address - Street 1:590 CANTERBURY DR
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48638-5876
Practice Address - Country:US
Practice Address - Phone:989-776-8033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301052183207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI198075810Medicaid
MI198075810Medicaid
MI0730927Medicare PIN