MEDICARE: RAJENDRA R SHROFF MD SC

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	207R00000X	Internal Medicine Physician		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0006100111	OTHER	IL	BLUE CROSS

General Provider Information

NPI Number	:	1831369735
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RAJENDRA R SHROFF MD SC

Provider Business Mailing Address
First Line	:	1050 M L KING DR STE 101
Second Line	:
City	:	CENTRALIA
State	:	IL
Zip	:	62801-3060
Country	:	US
Telephone Number	:	618-532-5700
Fax Number	:	618-532-7390

Provider Business Practice Location Address
First Line	:	1050 M L KING DR STE 101
Second Line	:
City	:	CENTRALIA
State	:	IL
Zip	:	62801-3060
Country	:	US
Telephone Number	:	618-532-5700
Fax Number	:	618-532-7390

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. BRENDA SUE LANCE
Credential	:
Telephone Number	:	618-532-5700

Provider Enumeration Date	:	03/06/2008
Last Update Date	:	03/06/2008

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