Provider Demographics
NPI:1780847384
Name:SHAH, ASHISH RAJESH (MD)
Entity Type:Individual
Prefix:DR
First Name:ASHISH
Middle Name:RAJESH
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 1:1615 N CONVENT ST STE 1
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-1081
Mailing Address - Country:US
Mailing Address - Phone:815-937-5200
Mailing Address - Fax:815-937-2063
Practice Address - Street 1:1615 N CONVENT ST STE 1
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1081
Practice Address - Country:US
Practice Address - Phone:815-937-5200
Practice Address - Fax:815-937-2063
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-136852207RG0100X
MI4301092339390200000X
NY273413207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036136852Medicaid