Healthcare Provider Details

I. General information

NPI: 1992124762
Provider Name (Legal Business Name): SHAJI MOHAMMED KHAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 02/20/2026
Certification Date: 02/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 W MEDICAL CENTER DR
MCHENRY IL
60050-8409
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 815-334-5566
  • Fax: 815-759-4008
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberS1840
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036-146640
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: