Healthcare Provider Details

I. General information

NPI: 1639481914
Provider Name (Legal Business Name): RAGHAV GOVINDARAJAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2010
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 SAINT ELIZABETH BLVD
O FALLON IL
62269-1281
US

IV. Provider business mailing address

3 SAINT ELIZABETH BLVD
O FALLON IL
62269-1281
US

V. Phone/Fax

Practice location:
  • Phone: 618-641-5803
  • Fax: 618-607-5116
Mailing address:
  • Phone: 618-641-5803
  • Fax: 618-607-5116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2013017438
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number2013017438
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: