Healthcare Provider Details

I. General information

NPI: 1669667242
Provider Name (Legal Business Name): RAJESH KANNAN ETHIRAJ M.D.,
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 BROADWAY ST
QUINCY IL
62301-2719
US

IV. Provider business mailing address

1005 BROADWAY ST
QUINCY IL
62301-2834
US

V. Phone/Fax

Practice location:
  • Phone: 217-223-6423
  • Fax: 217-223-6407
Mailing address:
  • Phone: 217-223-8400
  • Fax: 217-277-3960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number036121632
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License NumberU0017
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number56255
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: