Provider Demographics
NPI:1215910781
Name:IE, SUSANTI RAHAJU (MD)
Entity type:Individual
Prefix:DR
First Name:SUSANTI
Middle Name:RAHAJU
Last Name:IE
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 1:2001 CRYSTAL SPRING AVE SW
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-2462
Mailing Address - Country:US
Mailing Address - Phone:540-985-8505
Mailing Address - Fax:
Practice Address - Street 1:2001 CRYSTAL SPRING AVE SW
Practice Address - Street 2:SUITE 300
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-2462
Practice Address - Country:US
Practice Address - Phone:540-985-8505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050640207RC0200X, 207RP1001X
VA0101244044207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00927616AMedicaid
5791203OtherGHI
GA874218OtherBLUE CROSS BLUE SHIELD
4800175OtherUNITED HEALTHCARE
GA290014160OtherRAILROAD MEDICARE
GA0932200001OtherWORKERS COMPENSATION
1944925001OtherCIGNA
7024155OtherAETNA
H22046Medicare UPIN
4800175OtherUNITED HEALTHCARE