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NPI Code Detail

MEDICARE: DR. PREMKUMAR RAJA MD

MEDICARE: DR. PREMKUMAR RAJA MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12085R0001XRadiation Oncology Physician21336WV

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1689631442
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. PREMKUMAR RAJA MD
Provider Business Mailing Address
First Line : PO BOX 896158
Second Line :
City : CHARLOTTE
State : NC
Zip : 28289-6158
Country : US
Telephone Number : 304-388-1790
Fax Number : 304-388-1795
Provider Business Practice Location Address
First Line : 3415 MACCORKLE AVE SE
Second Line :
City : CHARLESTON
State : WV
Zip : 25304-1334
Country : US
Telephone Number : 304-388-1790
Fax Number : 304-388-1795
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/27/2006
Last Update Date : 06/23/2021

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