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General NPI Number Information
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NPI Number | 1669888491
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Entity Type | Individual
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Provider Name | RAJU KIRTIKUMAR SHAH MD
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Gender | Male
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Dates
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Enumeration Date | 07/01/2014
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Last Update Date | 09/04/2018
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Provider Practice Location Address
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Address Line | 5101 WILLOW SPRINGS RD 2ND FLOOR
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City | LA GRANGE
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State | IL
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Zip | 60525-2600
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Country | US
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Telephone | 708-245-8900
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Fax | 708-245-5604
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Provider Business Mailing Address
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Address Line | 4461 PROGRESS BLVD
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City | PERU
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State | IL
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Zip | 61354-1109
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Country | US
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Telephone | 815-223-9683
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Fax | 815-223-9683
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QG0300X
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Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
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License Number | 036143438
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | 125065796
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License Number State | IL
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