Provider Demographics
NPI:1104446467
Name:SURESH RAJA MD LLC
Entity type:Organization
Organization Name:SURESH RAJA MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SURESH
Authorized Official - Middle Name:
Authorized Official - Last Name:RAJAMANICKAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-767-0721
Mailing Address - Street 1:11104 GREEN BAYBERRY DR
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-1510
Mailing Address - Country:US
Mailing Address - Phone:561-767-0721
Mailing Address - Fax:561-429-6223
Practice Address - Street 1:11104 GREEN BAYBERRY DR
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33418-1510
Practice Address - Country:US
Practice Address - Phone:561-767-0721
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-16
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No261QR1100XAmbulatory Health Care FacilitiesClinic/CenterResearchGroup - Single Specialty