MEDICARE: RAJKUMAR PERIASAMY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	071010695	IL

General Provider Information

NPI Number	:	1013472752
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAJKUMAR PERIASAMY

Provider Business Mailing Address
First Line	:	666 DUNDEE RD STE 708
Second Line	:
City	:	NORTHBROOK
State	:	IL
Zip	:	60062-2734
Country	:	US
Telephone Number	:	312-900-8642
Fax Number	:

Provider Business Practice Location Address
First Line	:	666 DUNDEE RD STE 708
Second Line	:
City	:	NORTHBROOK
State	:	IL
Zip	:	60062-2734
Country	:	US
Telephone Number	:	312-900-8642
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2019
Last Update Date	:	08/04/2022

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Directions to “ RAJKUMAR PERIASAMY ” Practice Location

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