MEDICARE: RAJARAGHAVAN GOVINDARAJALU

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	5501007690	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G153730730341	OTHER	MI	DRIVER LICENSE
2	5501007690	OTHER	MI	BOARD OF PHYSICAL THERAPY

General Provider Information

NPI Number	:	1861993644
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAJARAGHAVAN GOVINDARAJALU

Provider Business Mailing Address
First Line	:	47600 ROYAL POINTE DR
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48187-5463
Country	:	US
Telephone Number	:	248-722-1156
Fax Number	:

Provider Business Practice Location Address
First Line	:	47600 ROYAL POINTE DR
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48187-5463
Country	:	US
Telephone Number	:	248-722-1156
Fax Number	:

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

Provider Enumeration Date	:	02/26/2018
Last Update Date	:	02/26/2018

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