Provider Demographics
NPI:1396711701
Name:SIVARAJAN, BHAVANI (MD)
Entity type:Individual
Prefix:DR
First Name:BHAVANI
Middle Name:
Last Name:SIVARAJAN
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 1:1715 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-5835
Mailing Address - Country:US
Mailing Address - Phone:815-744-1089
Mailing Address - Fax:815-744-0460
Practice Address - Street 1:1715 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5835
Practice Address - Country:US
Practice Address - Phone:815-744-1089
Practice Address - Fax:815-744-0460
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-24
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036072478174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036072478OtherLICENCE NUMBER
IL036072478Medicaid
IL036072478Medicaid
ILE69674Medicare UPIN