Healthcare Provider Details

I. General information

NPI: 1699976522
Provider Name (Legal Business Name): RAJIV SIDDARAMU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4742 N 24TH ST STE 300
PHOENIX AZ
85016-9107
US

IV. Provider business mailing address

3219 E CAMELBACK RD # 224
PHOENIX AZ
85018-2307
US

V. Phone/Fax

Practice location:
  • Phone: 602-753-8120
  • Fax:
Mailing address:
  • Phone: 602-753-8120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number37181
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number27432
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number37181
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: