MEDICARE: RAGHAVENDER RAO ENLAKOSIGI

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	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5501012356	OTHER	MI	LICENSE

General Provider Information

NPI Number	:	1366552903
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAGHAVENDER RAO ENLAKOSIGI

Provider Business Mailing Address
First Line	:	3005 LAKESHORE DR APT 214
Second Line	:
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-2356
Country	:	US
Telephone Number	:	269-369-5612
Fax Number	:

Provider Business Practice Location Address
First Line	:	3331 S STATE ST
Second Line	:
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-2458
Country	:	US
Telephone Number	:	269-982-1706
Fax Number	:

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/08/2007

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Directions to “ RAGHAVENDER RAO ENLAKOSIGI ” Practice Location

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