Healthcare Provider Details

I. General information

NPI: 1821319260
Provider Name (Legal Business Name): NISHA RAJA-RAHMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NISHA R RAMAMOORTHY MD

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 12/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 ENGINEERING AVE
SPRINGFIELD IL
62703-5909
US

IV. Provider business mailing address

1025 S 6TH ST
SPRINGFIELD IL
62703-2403
US

V. Phone/Fax

Practice location:
  • Phone: 217-528-7541
  • Fax:
Mailing address:
  • Phone: 217-528-7541
  • Fax: 217-528-8962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number036136824
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: