Healthcare Provider Details

I. General information

NPI: 1053440503
Provider Name (Legal Business Name): RAJ C SHAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S PAULINA ST SUITE 130
CHICAGO IL
60612-3806
US

IV. Provider business mailing address

600 S PAULINA ST SUITE 130
CHICAGO IL
60612-3806
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-3333
  • Fax: 312-942-4154
Mailing address:
  • Phone: 312-942-3333
  • Fax: 312-942-4154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number036101045
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: