Healthcare Provider Details

I. General information

NPI: 1073583746
Provider Name (Legal Business Name): SIVARAM RAJAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 ESSEX ST
HACKENSACK NJ
07601-3231
US

IV. Provider business mailing address

1 DIAMOND HILL RD
BERKELEY HEIGHTS NJ
07922-2104
US

V. Phone/Fax

Practice location:
  • Phone: 551-999-6433
  • Fax:
Mailing address:
  • Phone: 908-273-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number218115
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number12006
License Number StateNH
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number25MAO7423500
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2018209
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 2
Identifier30204220
Identifier TypeMEDICAID
Identifier StateNH
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: