Provider Demographics
NPI:1194823542
Name:BISHNU JIBAN RAUTH
Entity type:Organization
Organization Name:BISHNU JIBAN RAUTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BISHNU
Authorized Official - Middle Name:
Authorized Official - Last Name:RAUTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-522-5944
Mailing Address - Street 1:1836 LACKLAND HILL PKWY
Mailing Address - Street 2:ATTN: CREDENTIALING DEPARTMENT
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3572
Mailing Address - Country:US
Mailing Address - Phone:314-989-0300
Mailing Address - Fax:314-810-1399
Practice Address - Street 1:4351 E LOHMAN AVE
Practice Address - Street 2:STE 209
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8259
Practice Address - Country:US
Practice Address - Phone:505-522-5944
Practice Address - Fax:505-522-0636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty