1770597569 NPI number — PERUMALSWAMY RAJARAM MD

Table of content: PERUMALSWAMY RAJARAM MD (NPI 1770597569)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770597569 NPI number — PERUMALSWAMY RAJARAM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAJARAM
Provider First Name:
PERUMALSWAMY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770597569
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
321 E ROBERTSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRANDON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33511-5253
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-685-2191
Provider Business Mailing Address Fax Number:
813-689-8755

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40124 HIGHWAY 27 STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAVENPORT
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33837-5905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-421-7626
Provider Business Practice Location Address Fax Number:
863-419-2421
Provider Enumeration Date:
07/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  ME40960 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 014674000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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