Provider Demographics
NPI:1003823220
Name:SHAH, RIAZ (MD)
Entity Type:Individual
Prefix:
First Name:RIAZ
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 NE GLEN OAK AVE
Mailing Address - Street 2:SUITE 504
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61636-0001
Mailing Address - Country:US
Mailing Address - Phone:309-672-5729
Mailing Address - Fax:
Practice Address - Street 1:221 NE GLEN OAK AVE
Practice Address - Street 2:SUITE 504
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61636-0001
Practice Address - Country:US
Practice Address - Phone:309-672-5729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106955207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL472011OtherHEALTHLINK
IL0361069551Medicaid
IL7215059OtherBCBS PPO
IL075505OtherHEALTH ALLIANCE
ILIL01Q1OtherJOHN DEERE
IL110242961OtherRAILROAD MEDICARE
IL075505OtherHEALTH ALLIANCE
IL7215059OtherBCBS PPO