Healthcare Provider Details

I. General information

NPI: 1194248914
Provider Name (Legal Business Name): MOHAMED IHTESHAM SHAJI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2017
Last Update Date: 08/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 N MARINE DR
CHICAGO IL
60640-5759
US

IV. Provider business mailing address

DEPT OF GME, 4646 N MARINE DR 7TH FL STE 7100
CHICAGO IL
60640-5759
US

V. Phone/Fax

Practice location:
  • Phone: 773-564-7400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number125.069826
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: