Healthcare Provider Details

I. General information

NPI: 1568993657
Provider Name (Legal Business Name): KHAJA M. SIRAJ D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2017
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3815 HIGHLAND AVENUE SUITE AIP
DOWNERS GROVE IL
60515-1500
US

IV. Provider business mailing address

3815 HIGHLAND AVENUE SUITE AIP
DOWNERS GROVE IL
60515-1500
US

V. Phone/Fax

Practice location:
  • Phone: 708-283-5500
  • Fax:
Mailing address:
  • Phone: 708-283-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.070904
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036150771
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036150771
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number036.150771
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: