MEDICARE: NIRANJAN SHRESTHA M.D., FAAFP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	57009736	OH
2	207Q00000X	Family Medicine Physician	036.122701	IL

General Provider Information

NPI Number	:	1508031758
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NIRANJAN SHRESTHA M.D., FAAFP

Provider Business Mailing Address
First Line	:	1050 M L KING DR STE 111
Second Line	:
City	:	CENTRALIA
State	:	IL
Zip	:	62801-3060
Country	:	US
Telephone Number	:	618-436-5237
Fax Number	:	618-436-5236

Provider Business Practice Location Address
First Line	:	1050 M L KING DR STE 111
Second Line	:
City	:	CENTRALIA
State	:	IL
Zip	:	62801-3060
Country	:	US
Telephone Number	:	618-436-5237
Fax Number	:	618-436-5236

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/29/2008
Last Update Date	:	10/03/2012

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