=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144269432
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAJEEV DEVESHWAR M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2006
-----------------------------------------------------
Last Update Date | 12/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 MICHIGAN ST NE STE 6100 SPECTRUM HEALTH MEDICAL GROUP NEUROVASCULAR/STROKE OFFI
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49503-2561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-267-7900
-----------------------------------------------------
Fax | 616-267-7901
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 MICHIGAN ST NE MC845
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49503-2560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-486-6790
-----------------------------------------------------
Fax | 616-486-6702
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 036100789
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 036100789
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number | 036100789
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2084V0102X
-----------------------------------------------------
Taxonomy Name | Vascular Neurology Physician
-----------------------------------------------------
License Number | 4301053380
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number | 4301053380
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 4301053380
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------