Healthcare Provider Details

I. General information

NPI: 1548319239
Provider Name (Legal Business Name): RAJEEV SAI POLASANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 02/23/2022
Certification Date: 02/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE. DEPARTMENT OF RADIOLOGY
EVANSTON IL
60201-1057
US

IV. Provider business mailing address

2650 RIDGE AVE. DEPARTMENT OF RADIOLOGY
EVANSTON IL
60201-1057
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2477
  • Fax: 847-570-2942
Mailing address:
  • Phone: 847-570-2477
  • Fax: 847-570-2942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD428312
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number036120474
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: