Healthcare Provider Details

I. General information

NPI: 1619400397
Provider Name (Legal Business Name): MR. RAJU CHELLURI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2017
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LACKAWANNA AVE STE 200
SCRANTON PA
18503-2001
US

IV. Provider business mailing address

333 COTTMAN AVE
PHILADELPHIA PA
19111-2497
US

V. Phone/Fax

Practice location:
  • Phone: 570-342-7864
  • Fax:
Mailing address:
  • Phone: 215-728-6900
  • Fax: 215-214-1734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD478698
License Number StatePA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: