Healthcare Provider Details

I. General information

NPI: 1710113253
Provider Name (Legal Business Name): SHANKAR RAJESWARAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2009
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD DIVISION OF RADIOLOGY
PHILADELPHIA PA
19104-4319
US

IV. Provider business mailing address

2021 CHESTNUT STREET APT 705
PHILADELPHIA PA
19103
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-1190
  • Fax: 215-590-4668
Mailing address:
  • Phone: 610-453-2913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036-130483
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberMT196869
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: