Provider Demographics
NPI:1447291430
Name:KILARU, RAGHAVENDRA R (MD)
Entity type:Individual
Prefix:
First Name:RAGHAVENDRA
Middle Name:R
Last Name:KILARU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6085 COVERED WAGONS TRL
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-2100
Mailing Address - Country:US
Mailing Address - Phone:810-230-0055
Mailing Address - Fax:
Practice Address - Street 1:303 W WATER ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-5627
Practice Address - Country:US
Practice Address - Phone:810-232-2766
Practice Address - Fax:810-232-2782
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301041387101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
N47390010Medicare PIN