Provider Demographics
NPI:1700886231
Name:S. H. RAYTHATHA MD PC
Entity type:Organization
Organization Name:S. H. RAYTHATHA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SURENDRA
Authorized Official - Middle Name:HARIDAS
Authorized Official - Last Name:RAYTHATHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-872-5010
Mailing Address - Street 1:4672 HILL ST
Mailing Address - Street 2:
Mailing Address - City:CASS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48726-1028
Mailing Address - Country:US
Mailing Address - Phone:989-872-5010
Mailing Address - Fax:989-872-9942
Practice Address - Street 1:4672 HILL ST
Practice Address - Street 2:
Practice Address - City:CASS CITY
Practice Address - State:MI
Practice Address - Zip Code:48726-1028
Practice Address - Country:US
Practice Address - Phone:989-872-5010
Practice Address - Fax:989-872-9942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-27
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISR040618207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0790012OtherBLUE CROSS BLUE SHIELD
MI2763572Medicaid
MI0790012OtherBLUE CROSS BLUE SHIELD
MI2763572Medicaid